Need help for Insurance pre-approval paperwork

[meh]

Hello All:

I'm not sure whether this question belong to the pre-treatment option category or not as this is related to Insurance question before treatment.

Anyway, if anyone has dealt with Insurance about providing additional paperwork for choosing out-of-network hospital?

In my case, we selected Dr. Brackmann @ House for my 1.7+ cm AN on left based on reference and experiences heard from this forum (Thanks everyone at this forum for sharing your experience and opinion)

Unfortunately for my Insurance, Mcare-HMO, House clinic is out-of-network hospital.  So, I need to get special pre-approval from Mcare HMO.

In the first try, I received a letter from Dr. Brackmann for Insurance but Insurance denied based on this letter indicating that they have some in-network hospital they do the similar procedure. (which was kind of expected) So, I contacted House again. So, now they provided one more letter with more statistics for House clinic but I'm still not satisified with one page letter and very doubtful that insurance will just consider this one page letter and give me pre-approval.

I also looked at HEI and House Clinic website but no major luck.  I asked their staff but they said this one page letter should be okay and they don't have more statistics for how good their doctor and clinic is?  I'm bit disappointed with unsufficient information.

So, once again I thought that ANA forum should be my best hope. My question - Is there anyone who did some or extensive paperwork to get the pre-approval for out-of-network for any insurance company or anyone might know the criteria that they are looking to see for approving out-of-network hospital?

Any help/feedback would be greatly appreciated including some sample letters or paperwork.

Thanks again and have a good one!

[HeadCase2]

meh,
  It might be useful to try to get the same stats from the in-network hospital and surgery team that your insurance wants you to use.  If you can demonstrate that the in-network treatment history is not extensive enough for the best outcome, it may help.  Make them understand that this is a relatively rare condition that needs to be treated by a very experienced team of AN treatment experts.  Othewise it may cost them more in the long run to treat less than optimal after effects.
  Some of the others on this forum have had to convince their insurance company to approve out-of-network treatment.  They will be adding more info for you.
Regards,
 Rob

[Captain Deb]

Gennerally, your surgical counsellor at House should be handling all this paperwork for you--mine did. Have you gotten that far yet? House was in-network for me (even though the bone-heads as BCBS billed my entire bill as out-of-network--tooks months to straighten that one out) but I still had to get "certified" as it was out-of-state.
Good Luck,
Capt Deb

[gratus]

Hi!

I found an organization called the Patient Advocate Foundation which has a website patientadvocate.org that has a very informative, downloadable booklet called "Your Guide to the Appeals Process". Go to the website, and under Resources click on PAF publications; that will take to to a page where you can click on the appeals booklet. It concerns procedures, rights, etc.

Best wishes,
Joanne