Promise Health Plan CA Medi-Cal Denials
According to DHCS, about 34.3 percent of those eligible for Medi-Cal are adults between the ages of 19 and 64, 38 percent are parent/caretaker relative and child, with the remainder being seniors and those with disabilities, adoption and foster care children, children in the CHIPS program, and those in long-term care. Medi-Cal offers health care to those who otherwise might not have health care. So while you may be grateful for your Blue Shield Promise Medi-Cal health insurance plan, receiving a denial for a needed service can be extremely distressing. This is a situation that will vastly benefit from speaking to attorney Scott Glovsky. Scott helps people in similar situations every day, working hard to ensure justice is done. Don’t let your Blue Shield Promise Medi-Cal denial be the final word. Scott and his legal team are ready to help you through this difficult time.
What Are Medi-Cal Plans?
Serving almost a third of all Californians, Medi-Cal provides low-income residents (and those with no income) with access to affordable, high-quality health care. County human services departments administer Medi-Cal at local levels. Your county of residence will determine your plan options. While most counties offer plans including Anthem Blue Cross, Molina, Promise, Health Net, Kaiser Permanente, and more, others offer public plans administered by the community. If your county only administers one plan, then as a Medi-Cal member, you will be required to enroll in that plan.
More than three-quarters of all Medi-Cal plans are considered “managed care plans,” meaning they function much like an HMO. As with an HMO, you will have a primary care physician who will refer you to a specialist if you have medical needs that require a specialist. If you have a medical emergency, you will not be limited to a specific hospital, although if you have a planned medical procedure, you will use the hospital in your plan’s network. Your clinic, pharmacy, and specialists must also be in-network under your Medi-Cal plan.
You can apply for Medi-Cal by mail, in person, or online. As of May 1, 2016, undocumented low-income children under the age of 19 are eligible for Medi-Cal coverage. “Typical” Medi-Cal services include hospitalization, emergency services, outpatient services, maternity and newborn care, mental health treatments, prescription drugs, preventative and wellness services, chronic disease management, children’s services, laboratory services, and physical and occupational services.
What Counties Offer Promise Health Medi-Cal Managed Care Plans?
Blue Shield of California Promise Health Plan has Medi-Cal Managed Care plans in San Diego and partners with L.A. Care Health Plan in Los Angeles.
Do Promise Health Managed Care Plans Work with Independent Physician Associations (IPA)?
Blue Shield of California Promise Health Medi-Cal Managed Care plans work with IPAs. Independent Practice Associations are independent medical groups with their own practices – sometimes including facilities like hospitals, imaging centers, urgent care centers, and more. When a health insurer works with an IPA, it usually has the IPA approve and deny medical care. You can learn about IPAs here.
Blue Shield Promise Insurance Provider and Its Medi-Cal Plans
Blue Shield Promise Medi-Cal serves California residents in Los Angeles and San Diego counties, allowing enrollees to access free or low-cost health coverage for adults and children who qualify. Promise Health Plan is an HMO owned and operated by Blue Shield of California and was formerly known as Care 1st Health Plan. In Los Angeles County, Blue Shield Promise has partnered with L.A. Care Health Plan to open 14 L.A. Care and Blue Shield Promise Community Resources. In addition to “typical” health insurance benefits, Blue Shield Promise offers interpreters for more than 240 languages, a 24/7 Nurse Advice Line, wide access to doctors, specialists, hospitals, and clinics, free rides to medical appointments, and home-based care for certain conditions.
What Types of Services Might Blue Shield Promise Deny?
All insurance companies issue denials for services, although some issue more denials than others. A Blue Shield Promise denial could be issued if there is an error when the claim was filed, or if there was incomplete information in the claim documents. You may have failed to obtain pre-authorization for a procedure that required it, or your plan may simply not cover the procedure or drug, as stated in your policy.
Unfortunately, there are more nefarious reasons you may receive a Blue Shield Promise denial for a procedure, test, or prescription drug. Insurance companies are primarily interested in their financial bottom line, so if your claim includes a particularly expensive drug, test, or procedure you may receive a denial that includes one or more of the following words or phrases: “investigational,” “experimental,” “not medically necessary.” It can be extremely demoralizing to have your doctor prescribe a treatment that is then denied by your health insurer.
A 2020 audit of Blue Shield Promise was conducted by DHCS which had some concerning results. Auditors found that Promise did not include a review of grievances and appeals of prior authorization denials and was not following the proper procedures for determining what level of service Medi-Cal members were entitled to. Many Promise Medi-Cal members rely on covered transportation to access medical care, but lapses in Promise health plans caused many Californians to be unable to receive the transportation benefit.
What Steps Should You Take if Promise Denies Your Medi-Cal Claim?
A Blue Shield Promise Medi-Cal managed care denial can be devastating when are ill or injured. When your doctor prescribes a treatment, test, or prescription drug, it is because he or she believes your health will benefit. To have a Blue Shield Promise Medi-Cal managed care denial can make you lose hope for your health and your future. Having a strong insurance claim denial attorney from the Law Offices of Scott Glovsky during this difficult time can make a significant difference in the outcome of your denial.
Knowing why your claim was denied is essential before you start the process. You should have received a “Notice of Action” (NOA) letter from Blue Shield Promise Medi-Cal that details why your claim was denied. If the denial is due to an error or other issue that can be easily corrected, you can correct the problem and resubmit your claim. If you’ve received a denial that says the medical treatment in question has been denied because it is not medically necessary or is experimental or investigational, you and your attorney can start the appeal process.
First, you have sixty calendar days to file an internal appeal which asks Blue Shield Promise Medi-Cal to reconsider its initial denial. The company has 30 days from the date it receives your complaint toapprove the denied treatment or to still deny the treatment. If your appeal is a serious threat to your health, Promise must respond to your appeal in 72 hours. Promise Health’s decision will come in a letter called, “Notice of Appeal Resolution (NAR).” If Blue Shield of California Promise Health Plan doesn’t send you a NAR withing 30 days, you may ask for a State Hearing from the California Department of Social Services (CDSS). You can find more information about the appeal process in the Member Handbook, also known as the Combined Evidence of Coverage (EOC) and Disclosure Form.
If Promise Health continues to deny the treatment, you can file an external appeal with a neutral third party. The Department of Managed Healthcare handles this process known as an Independent Medical Review or IMR. Whatever the outcome of this external appeal, Promise is bound by the decision. If the external appeal reverses the denial, then Promise Health must pay for the treatment. Your Member Handbook has all the information you need regarding both internal and external appeals, but having an attorney by your side gives you a much greater chance of a positive outcome since your lawyer knows the process and can help guide you to optimize your chance of success.
Note that with a Medi-Cal Rx pharmacy denial, you can request a state hearing but not an IMR.
How the Law Offices of Scott Glovsky Can Help With a Promise Medi-Cal Managed Care Denial
When you are facing a Blue Shield Promise Medi-Cal managed care denial, it is essential that have someone on your side who is experienced, knowledgeable, and will fight for justice on your behalf. Attorney Scott Glovsky is that person. Scott began his legal career working on the “other” side—for big corporations. Because of this, he has a deep understanding of the tactics used by insurance companies.
Scott is more prepared, more focused, and always ready to stand firmly on the fair and just side of the argument. Scott and his legal team understand how devastating a health claim denial can be. We are empathetic to your situation and always provide highly personal, individualized attention to your issue that you are unlikely to find elsewhere. Contact the Law Offices of Scott Glovsky today.