As a medical patient, you likely trust your doctor to recommend the necessary tests and treatments for whatever ailments you may have. Your doctor has the training and experience to determine your medical needs.
However, some insurance companies like Anthem Blue Cross and Blue Shield of California require their policyholders to seek a medical necessity preauthorization prior to having certain procedures, treatments, or purchasing medical supplies.
They can then deny your treatment and claim that there is no medical necessity for what your doctor has ordered or recommended. While some of these denials may be honest mistakes, many are intentional and meant to save the insurance carrier money. If you have experienced Anthem Blue Cross of California medical necessity denial in Los Angeles, take back control of your health by calling a seasoned health insurance denial attorney.
The Legal Rights of Anthem Blue Cross of California Policyholders
What many patients do not understand is that they can take action when they are denied a preauthorization for treatments or services. However, the process to do so differs depending on whether the insurance policy is governed by the Employee Retirement Income Security Act (ERISA) or is a non-ERISA health insurance policy.
ERISA, under 29 U.S. Code § 1132, generally controls employer-provided insurance plans, unless the employer is the government or a church entity. Plans purchased by an individual are usually not governed by ERISA. The process for challenging a medical necessity denial can be arduous and confusing, therefore, anyone who is considering appealing a denial may want the help of an experienced attorney to fight for their rights to an approval.
Appeals Process in Los Angeles
For non-ERISA insurance, a patient or their physician may choose to file an appeal for their Anthem Blue Cross of California medical necessity denial in Los Angeles. The insurer’s denial should state how to start an internal appeal. It is most effective to send a letter from the policyholder’s doctor detailing why the denial was wrong and why the treatment is medically necessary. The letter should include certain information and be very specific as to why the patient needs the denied treatment or service.
An insurance attorney can help increase the chances that an appeal will succeed since an experienced attorney will be familiar with the process and know what is required. Many times, in non-ERISA cases, the court will interpret any ambiguous plan terms in favor of the insured individual and an attorney can help advocate for those rights.
Option for an Independent Medical Review
In addition to filing an appeal, in some circumstances, the policyholder can also seek an independent medical review (IMR) from an appropriate state regulatory agency. This review of a request is done by an independent medical professional or professionals who will evaluate whether the decision the insurance company made was supportable.
However, in California, a policyholder can only request an IMR if their insurance carrier denied, changed, or stalled a service or treatment due to its determination that it was not medically necessary.
A person can also request an independent review if they have a serious medical diagnosis and the carrier refuses to pay for treatments that are experimental or investigational or if the insurance company denies payment for emergency or urgent care after the person already received the care and the denial was based on medical necessity.
Challenging the Insurance Carrier for a Medical Necessity Denial
Policyholders usually have the option to challenge the insurance carrier in court. The only requirement for most non-ERISA policies is that the insurance company denied treatment. Through a lawsuit, an attorney will strongly encourage an insurance company to revisit and reconsider their denial. In addition to paying for a denied claim, an insurance carrier may also be responsible and liable for their bad faith actions in court. For more information on an Anthem Blue Cross of California medical necessity denial in Los Angeles, contact an attorney today.
Seeking Legal Representation for Medical Necessity Denial in Los Angeles
If you have been affected by an Anthem Blue Cross of California medical necessity denial in Los Angeles, contact a skilled attorney today. An attorney experienced in facing larger insurance carriers such as Anthem could help ensure that you receive the coverage that you deserve.
An experienced lawyer could help you in this process and may help relieve some of your stress, take away some financial burdens, and hold your insurance company accountable for their actions. Call today so an experienced attorney can help you get the coverage you deserve.