Regence Blue Cross And Blue Shield Of Utah

Mr [redacted] is on a Regence BlueShield of Washington policyIn September Regence mailed letters to all members currently taking TestosteroneThis letter was to advise that preauthorization would be required in order to continue use of Testosterone, not to advise that we would no longer be covering Testosterone for all membersRegence received a preauthorization request for Mr [redacted] on September 18, A letter granting approval from September 18, through September 18, was mailed to him on September 29,

A first and second level appeal was submitted to Regence regarding [redacted] ***'s concerns associated with her inpatient stay at UC San Diego Medical Center. Per her group's contract, room and board is limited to the Hospital's average semiprivate room rate, except where a private room is... determined to be necessary. Based on the medical documentation received with [redacted] ***'s first and second level appeal, a Medical Director reviewed this information, and determined that the use of a private room was not medically necessary. The clinical documentation did not confirm a private room was medically necessary for monitoring, isolation, extra providers, or for unusual procedures. Therefore,these services were denied as a contract exclusion. It is important to note that the first and second level appeal was reviewed by two separate Medical Directors. Following the second level appeal determination on November 24, 2014, a request for an external review was submitted to an Independent Review Organization (IRO). An IRO has no association with Regence, and by choosing an external appeal, this is the members final appeal rights as the decision is binding. The Medical Review Institute of America conducted the external review. They performed an independent review of the proposed/rendered care to determine if the adverse benefit determination was appropriate. Medical records were reviewed as well as the documentation provided by the involved parties. On March 25, 2015 a decision was made to uphold the denial. A copy of this IRO was sent to the claimant and Regence on March 25, 2015. Regence regrets that we are unable to grant [redacted] ***'s request in paying for the charges that were billed above the standard room rate. As previously shared with [redacted] ***, the external review decision that was conducted by the Medical Review Institute of America is binding. Sincerely, Teresa *. P [redacted] Legal Department Regence BlueShield of Idaho [redacted] @regence.com ###-###-#### FAX ###-###-####

Complaint: ***
I am rejecting this response because:UCSD does not differentiate between the private and semi-private rooms and they are billed at the same ratePatients are assigned to private rooms if they are available, otherwise to semi-private roomsIf you call UCSD billing they will confirm thisAs mentioned in the original complaint, we were never asked to chooseRejection to cover asking for proof of medical necessity in spite of the fact that they are treated the same by the hospital seems like a practice to deny genuine claims, something I am finding based on my investigation has been done with others by this insurance as well. I don't need any further help from Revdex.com as I have legal counsel advising me on next stepsThanks Revdex.com as always for representing the consumer
Sincerely,
*** ***

Mr. [redacted] is on a Regence BlueShield of Washington policy. In September Regence mailed letters to all members currently taking Testosterone. This letter was to advise that preauthorization would be required in order to continue use of Testosterone, not to advise that we would no longer be covering...

Testosterone for all members. Regence received a preauthorization request for Mr. [redacted] on September 18, 2015. A letter granting approval from September 18, 2015 through September 18, 2016 was mailed to him on September 29, 2015.

A first and second level appeal was submitted to Regence regarding [redacted]'s concerns associated with her inpatient stay at UC San Diego Medical Center. Per her group's contract, room and board is limited to the Hospital's average semiprivate room rate, except where a private room is...

determined to be necessary.
Based on the medical documentation received with [redacted]'s first and second level appeal, a Medical Director reviewed this information, and determined that the use of a private room was not medically necessary. The clinical documentation did not confirm a private room was medically necessary for monitoring, isolation, extra providers, or for unusual procedures. Therefore,these services were denied as a contract exclusion. It is important to note that the first and second level appeal was reviewed by two separate Medical Directors.
Following the second level appeal determination on November 24, 2014, a request for an external review was submitted to an Independent Review Organization (IRO). An IRO has no association with Regence, and by choosing an external appeal, this is the members final appeal rights as the decision is binding.
The Medical Review Institute of America conducted the external review. They performed an independent review of the proposed/rendered care to determine if the adverse benefit determination was appropriate. Medical records were reviewed as well as the documentation provided by the involved parties. On March 25, 2015 a decision was made to uphold the denial. A copy of this IRO was sent to the claimant and Regence on March 25, 2015.
Regence regrets that we are unable to grant [redacted]'s request in paying for the charges that were billed above the standard room rate. As previously shared with [redacted], the external review decision that was conducted by the Medical Review Institute of America is binding.
Sincerely,

Teresa *. P[redacted]
Legal Department
Regence BlueShield of Idaho
[redacted]@regence.com
###-###-####
FAX ###-###-####