Health Insurance Appeals, Assistance & Providers
Appendix Cancer, Pseudomyxoma Peritonei, Peritoneal Surface Malignancies
Health Insurance Resources for PMP Cancer, Appendiceal Cancer
Pal, Ed, answers your questions!
Are you seeking resources for health insurance for the treatment of Appendix Cancer, Colorectal Cancer, Pseudomyxoma Peritonei, and related diseases?
Are you seeking assistance preparing an appeal after your request for coverage, or payment for a procedure/treatment, including HIPEC, has been denied?
Our Pal, and fellow appendix cancer survivor, Ed, pictured here, is a retired hospital administrator and shares expert suggestions for addressing any health insurance question.
Scan the resources listed below for information that may be helpful to you.
For more detailed information, new "Pal" members receive the:
PMP Pals' Network Handbook: Resources for Patients and Caregivers
For additional resources and helpful articles, visit our blog library of health insurance articles!
Medicare Patients Affected by Sequester Cut Backs
Photo courtesy of KOTV
Medicare Patients Starting to Feel Sequester Pain
CBS News examines effects of sequester on Medicare cancer patients
Source: CBS News 04.03.13
Appendix Cancer and Pseudomyxoma Peritonei Treatment
Health Insurance Coverage
HIPEC Coverage
Insurance Providers Cover HIPEC for Pseudomyxoma Peritonei Treatment
Do you need help convincing your health insurance provider to cover the costs of HIPEC and CRS?
"Click" on the following website links for additional information:
Insurance and Appeals assistance for HIPEC coverage of payment
Source: ThermaSolutions, Inc.
Aetna Insurance Approves Payment for CRS with HIPEC for Pseudomyxoma Peritonei Treatment
Source: Aetna, 2009
Aetna:HIPEC payment for Pseudomyxoma Peritonei treatment
Blue Cross Blue Shield of MS Approves Payment for CRS and HIPEC for Pseudomyxoma Peritonei Treatment
Source: Blue Cross Blue Shield, October 2009
Blue Cross Blue Shield of MS Medical Technology Assessment Guidelines
(criteria for approving/disapproving HIPEC, CRS, for Peritoneal Carcinomatosis, etc.)
Source: Blue Cross Blue Shield
Blue Cross/Blue Shield Empire
Source: Blue Cross Blue Shield
"The 2006 Blue Cross Blue Shield Empire newsletter lists Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy (96445) Cytoreduction and hyperthermic intraperitoneal chemotherapy is medically appropriate for the treatment of pseudomyxoma peritonei. It is investigational for all other indications."
CIGNA approves payment for CRS and HIPEC for Pseudomyxoma Peritonei Treatment
Source: Cigna
How to Help Patients to Pay Their Bills
Out of Network Fees
Negotiating with your medical insurance provider
How Can I Convince My Medical Insurer to Pay for Newly Marketed Cancer Treatment Drugs?
Source: Web MD 12.11.12
Balancing Cancer Care with Healthcare Costs
Managing Your Personal Medical Records
Managing Your Personal Health Records
Prepare Your Medical Resume
Source: PMP Pals' Network
Minerva Software: Health records management system
Managing Your Medical Bills & Health Insurance Claims
Prescription Drug Plans
"Click" on the following website links for additional information:
Get help with prescription drug costs!
Source: PMP Pals' Network
Prescription Rx Payment Assistance, United States
Lilly Patient Assistance Program
Novartis Patient Assistance Program
"Shop Around" for Part D Medicare Prescription Coverage
Source: AARP December 2009
Prescription Side Effects
Prescription Side Effects
FDA toll free number: 1.800.FDA.1088
HIPEC: CPT Codes for CRS and HIPEC
Current Procedural Terminology or CPT codes are designated to every medical procedure including diagnostic, medical, and surgical care. Health insurance providers use CPT codes to determine the amount of reimbursement that a health care provider will reimbursed by an insurer.
Insurance codes for CRS HIPEC
Chemotherapy administration peritoneal cavity 96445
Exploratory laparotomy 49000
Hyperthermia, externally generated 77605
Insertion of intraperitoneal cannual or catheter 49419
Peritoneal chemotherapy 96446
Small bowel resection 44120
Tumor debulking 49203
Medicare for HIPEC 96445
Insurance codes for CRS HIPEC
Chemotherapy administration peritoneal cavity 96445
Exploratory laparotomy 49000
Hyperthermia, externally generated 77605
Insertion of intraperitoneal cannual or catheter 49419
Peritoneal chemotherapy 96446
Small bowel resection 44120
Tumor debulking 49203
Medicare for HIPEC 96445
Canadian Health Insurance Resources
Healthcare Costs: Germany
Healthcare Costs: United Kingdom
Health Insurance Benefits, USA
US Government Benefits
"Click" on the following website links for additional information:
National Association of Health Insurance Commissioners Listing for all 50 States and Territories
Concerns About Providing Medical Insurance for All Americans
Health Care and Social Service Benefits
Disability Benefits for Social Security
National Association of Health Underwriters
Consumer "checkbook" for health insurance and hospitals in US
Consumer Guide for Getting and Keeping Health Insurance for all 50 States
Source: Georgetown University
What you should know about health insurance
Source: US Dept of Health and Human Services
Consumer Guide to Group Health Insurance Policies
Source: NAHU
US Government COBRA, Nationwide
COBRA: Consolidated Omnibus Budget Reconciliation Act
US Government Financial Aid & Benefits
Benefits Checkup
Take this confidential questionnaire to find out what type of assistance you qualify for from several different organizations. This is an excellent resource!
Disability Benefits for Social Security
US Government Medicare & Medicaid
CMS: Centers for Medicare and Medicaid: All you need to know for resources, coverage and providers
Cancer Costs Have Nearly Doubled During Past 20 Years
Source: Kaiser Health News May 2010
High cost of cancer care may lead to Post Traumatic Stress Disorder
Source: Dotmed.com April 2010
Health Insurance Ages 50+
AARP
AARP Medicare Supplemental Insurance
Free access to AARP online bulletin!
Healthnet Medicare Supplement Insurance
Scan Healthcare Plan provides Medicare related coverage to residents of selected counties/regions in CA and AZ
Dental Insurance ages 50+ (Delta Dental via AARP)
Medicare
Disabled Americans age 21+ and/or all Americans age 65+ may be eligible for Medicare benefits.
FAQs About MediCare Open Enrollment
Medicare Provides Annual Wellness Exam
Tips for Choosing a Medicare Plan
Colon Cancer Screenings
Medicare Appeals Process
Billing Advocates of America
MediCare Explained by United Healthcare
Source: United Healthcare
Medicare
California Advocates for MediCare: MIPPA of 2008 and 2010
Source: California Advocates
MediGap Options
Medicare Appeals Process (for when your claim has been denied)
Concise, step by step instructions for appealing a denial are provided in the December 2008 issue of the Phoenix Magazine pages 22-24. Medicare Appeals Forms
Medicare code for HIPEC coverage: 96445
California Healthcare Foundation
California Healthcare Foundation
Supporting ideas and innovations to improve healthcare for all Californians
Health Consumer Alliance of California
Health Consumer Alliance of California
The Health Consumer Alliance helps low income Californians obtain the healthcare they need!
California Health Insurance Resources
California Health Access
Source: Health Access
California Advocates for MediCare Patients
Source: California Advocates
"Making Insurance Companies Pay" informative article
Source: New York Times, February 5, 2010
Insurance and Appeals assistance for HIPEC coverage of payment
Source: ThermaSolutions, Inc.
Patient Advocate Foundation (advocacy, appeals and more!)
Provides legal counseling and referrals regarding managed care, HMOs, health insurance, and debt crisis matters.
Phone, toll free: 888 532 5274
California Health Insurance Issues and Benefits
California's Major Risk Insurance Program (for patients unable to obtain health insurance
California Health Care Rights
Health Insurance Premium Payment (HIPP) for Californians through MediCaid/MediCal
Call, toll free: 1.866.298.8443
SSI/SSP Benefits for Californians Change in 2009
California Advocates for MediCare: MIPPA of 2008 and 2010
Source: California Advocates
Medigap Plans
Health Insurance and Billing for UCSD
Health Insurance and Billing at UPMC
How to File a Health Insurance Appeal
Advocacy and Insurance Appeals for Patients, United States
Do you need an advocate to assist you with your health insurance claim, appeals, or medical bills?
Do you need help filing an insurance appeal?
"Click" on the following website links for additional help and information:
How to File a Health Insurance Appeal
Source: PMP Pals' Network Library
How to File an Appeal when your Claim is Denied
Source: PMP Pals' Network
National Association of Health Insurance Commissioners: Listing for all 50 States and Territories
Cancer Care Co Payment Foundation
Patient Advocate Co Payment Fund
Healthwell Foundation Co Payment Fund
Patient Advocate Foundation
Provides legal counseling and referrals regarding managed care, HMOs, health insurance, and debt crisis matters.
Phone, toll free: 888 532 5274
eHealthInsuranceHealth Insurance Information
National Association of Health Insurance Commissioners
How to Appeal a Denial from your Health Insurance Provider (including denials for HIPEC treatment)
Medical Bill Claims Assistance
Medical bill claim assistance professionals in your area
Source: CAPS
Medical Bill Auditing Services
True Facs: Medical bill auditing
Source: TrueFacs
HIPEC: Insurance Coverage
Click here to read about HIPEC, including the International Consensus Advocating HIPEC as the treatment of choice
Suggestions for filing an appeal when you insurance claim has been denied
Before scheduling treatment, check for the following:
Does your plan provide out of network coverage?
Is your provider an HMO (Health Maintenance Organization)?
Is your provider a PPO (Preferred Provider Organization)?
Keep your health insurance card on hand. The card includes identifying information about your policy, including co payments.
Before you get started with the appealing the denial of coverage, check for the following:
Policy exclusions and restrictions
Denials may be made because the policy specifically excludes coverage of a certain treatment, procedure or medicine. Contact your insurer’s case management department to confirm whether specific costs are covered (ideally, this should be done before you are admitted to the hospital for treatment.)
Organize your paperwork
Organize all the information you need from your insurer before you start the appeal process. The "explanation of benefits" should provide a code for the reason your treatment(s) was denied. If you cannot locate the code, ask your insurer to provide it.
Notate the name, date, time, phone number, and extension of each person you talk with, whenever you call your health insurance provider.
Find out exactly to whom the appeal should be addressed and mailed. Keep copies of any written correspondence and send it via registered mail, requesting a return receipt.
Clerical and coding errors
Check to see whether the denial was due to a clerical or coding error. If the denial was due to an error, have your hospital, or physician's billing clerk, correct the error and provide you and the health insurance provider with a corrected copy of the bill, with the correct code.
Reason for denial
Specifically, why was your claimed denied? Follow the guidelines of the “denial letter.” Customize your appeal, specifically for the reason your claim was denied.
Time limitations
Most insurers set aside a time period during which a patient may file for an appeal. Check your policy to determine this time limit, which may be 60, 90 or 180 days. Monitor time limitations so you don't miss the deadline for your appeal.
Emergency Out of Network Care
Coverage/reimbursement of an out-of-network emergency claim, will require proof
1) Of the medical emergency and
2) Confirmation that no in-network provider was readily available, within reasonable proximity of the emergency. Use your emergency medical records, with doctors' notations, to support your claim.
"How to Get Out of Network Fees Covered"
Source: New York Times, Sept 2010
Experimental Protocols/Treatment
HIPEC is more commonly denied for payment as “experimental” medical treatment among our fellow patients than any other protocol/treatment. The surgical oncologist who proposes treating you with HIPEC should be your first line of defense for this type of denial. He/she should be prepared to provide you with a letter stating that HIPEC (or any other treatment being denied) is the established protocol/treatment method for your specific diagnosis. His/her letter can be accompanied by medical journal publications by that surgeon or others, as noted in the red Alpha Index section of medical journal articles posted on the Pseudomyxoma Peritonei page at www.pmppals.org
State Appeals Review Boards
If you receive coverage directly from an insurance company, your insurer is regulated by your state’s insurance department. With the exception of Alabama, Mississippi, Nebraska, South Dakota and Wyoming, patients in all other states are allowed to have their appeals considered by an independent external appeals review board. Generally, the review board consists of physicians and other healthcare providers with expertise in your disease. Contact your state department of insurance for more information.
Additional assistance
Advocacy groups will assist you at no charge. An extensive listing of patient advocacy groups is posted on the Health Insurance page at www.pmppals.org
Articles posted in PMP Pals and on www.pmppals.org are written from the perspective of patients and their families and are not intended to substitute for licensed, professional, legal or medical advice. Patients should seek the counsel of their licensed healthcare providers. Copyright © 2011 by PMP Pals’ Network/All rights reserved. Visit us on the web at www.pmppals.org
Ostomy Care
Coverage for Ostomy Supplies Becoming Limited
Source: The Phoenix Magazine, March 2009 by Colin Cooke
Authorization of Payment for Medical Treatment
1. Clarifications Regarding Authorization of Payment for Surgery, Chemotherapy, HIPEC
2. General Definitions for Health Insurance Providers’ Coverage Patients are responsible for confirming the active status of their health insurance coverage policies/prior to receiving scheduled medical treatment including surgery, HIPEC and systemic chemotherapy.
Check with your specific health insurance provider for details pertinent to your particular policy. Generalized definitions are as follows:
Precertification:
The process followed to obtain prior authorization for services (Pre-service) that require approval
by your health insurance provider, in whole or in part, before the service is rendered; a service that must be
approved in advance before it is rendered in order for the service to be eligible for reimbursement without penalty.
Failure to obtain precertification for otherwise covered medically necessary services may result in a payment
penalty for the patient/member, provider or both.
Retro-certification:
A request for services or a request for payment of services, which have already been rendered (Post service). Retro-certification occurs when notification is received by your health insurance provider after the care/service has been provided.
Emergency Care:
An "emergency condition" means a medical condition manifesting itself by acute symptoms of sufficient severity. Specific definitions of emergency care, are outlined in your health insurance provider’s member's benefits literature.
Urgent Care:
Medical care for a condition that needs immediate attention to minimize severity and prevent complications but is not a medical emergency.
Network Provider:
A Physician, Certified Nurse Midwife, Hospital, Skilled Nursing Facility, Home Health Care Agency or any other duly licensed or certified institution or health professional under contract with your health insurance provider to provide covered services.
Primary Care Physician (PCP):
A Network provider who: maintains continuity of patient care; provides initial care and basic medical services; and initiates referrals for specialty care.
Durable Medical Equipment (DME):
DME is equipment which is: designed and intended for repeated use; primarily and customarily used to serve a medical purpose; generally not useful to a person in the absence of disease or injury; and appropriate for use in the home.
Prescription Medication: Refer to your health insurance provider for specifics.
In-Network Coverage:
Services provided by a patient’s PCP, OB/GYN or Network Provider upon referral from the PCP (for those plans which require a referral), paid subject to the patient/member's in-network cost share specified in the member's summary of benefits and when properly precertified, if required.
Out-of-Network Coverage:
Services provided by any individual provider or facility who is not a Network provider and, therefore, considered outside of the member's network. Depending on the health insurance provider, fees may be subject to the patient/member's applicable out-of-network deductible, cost share and /Medicare Fee Schedule (if applicable) as specified in the patient/member's summary of benefits.
Usual Customary and Reasonable (UCR) Charge:
A UCR schedule is a compilation of maximum allowable charges for various medical services which varies by geographic location.
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Non-Emergency Admissions to Health Care Facilities or Scheduled Procedures:
Non-emergency admissions to health care facilities, including maternity and surgery, and certain diagnostic tests and therapeutic procedures as outlined in the health insurance providers members' Summary of Benefits must be precertified prior to the patient/member being admitted or receiving treatment. Providers and patient/members should notify their health insurance provider prior to a scheduled procedure or admission to begin the Precertification process.
Emergency admissions to Health Care Facilities:
Generally, patient/members, or their designee, must notify their health insurance provider of all emergency admissions no later than 48 hours from the date of admission, or as soon as reasonably possible.
Emergency Room Visits:
Hospital Emergency Room visits do not require Precertification or notification after services are received.
Urgent Care Visits:
Urgent care visits to contracted urgent care centers (in the service area only) do not require Precertification. For Medicare Members, urgent care visits to urgent care centers (both in and out of the service) do not require precertification.
________________________________________
Procedures and Responsibilities
In Network Services:
Network Providers are responsible for obtaining precertification for all procedures requiring precertification performed by Network physicians and surgeons, even if the Member does not have a valid referral from their PCP. Network physicians are responsible for notifying the healthcare insurance provider when there has been a change of treating physician, procedure codes or dates of service. For contracted facilities the requirement is that admission notice must occur upon admission or on the day of admission. If the hospital is unable to determine on the day of admission that the patient is an insured, the hospital will notify the health insurance provider as soon as possible after discovering that the patient has coverage.
Out-of-Network Services:
For out-of-network providers not referred by the Member's PCP, the patient/member is responsible to contact the health insurance provider and initiate the precertification process.
Precertification Guidelines:
Services that require precertification by the health insurance provider may be approved for payment as either in-network or out-of-network based on the Member's plan and the status and type of provider rendering or performing the service. For example: Physician performing the service (e.g., physician performing surgery): Generally, the status of the physician performing the service determines if the services will be precertified in or out-of-network. Vendor rendering the service (Durable Medical Equipment (DME) vendor): Both the status of the referring provider and the rendering vendor determine if the service will be precertified in or out of-network.
Medicare Plans:
All durable medical equipment requires Precertification for Medicare Members.
Retro-certification (no Precertification is on file): Not applicable for Medicare Members.
When services require precertification and precertification has not been obtained, based on the Member's benefits, status of the provider and applicable state regulations, a penalty may be applied to services that have been determined to be both medically necessary and a covered benefit under the Member's Benefit Plan.
Based on state regulations, the penalty may be a percentage (%) of charges, percentage (%) of charges up to a specific dollar limit, or an increase to the Member's coinsurance that the Member will be responsible to reimburse to the provider.
The above statements are guidelines only and are subject to all State and Federal laws and regulations.
Health Insurance Articles of Interest!
Tips on purchasing Health Insurance from an industry insider
Source: NY Times, Feb 18, 2011
Tips for Negotiating Healthcare Costs
Source: Web MD, Jan 2011
Concierge Medical Care Options Increasing
Source: NY Times, Jan 31, 2011
Blue Book of Healthcare Services
Compare costs of healthcare in your region
Health Insurance Companies Owe Rebates
Health insurers owe rebates to many California policyholders
Source: LA Times 06.02.12
Anthem Blue Cross, Blue Shield of California and Kaiser Permanente are to distribute more than $50 million in rebates across some 1 million California customers.
Thank you to our family sponsors!
This web page is sponsored by an anonymous couple in appreciation for their son's good health!
Please respect your fellow patients and caregivers by not copying or cutting and pasting any pages from this website onto yours.
The PMP Pals Network is a volunteer patient advocacy program. We support the services that we provide, including this web page, as volunteers and through subscriptions to our publications.
We neither solicit nor receive funds from pharmaceutical companies or healthcare providers, thus maintaining our dedication to serving as patient advocates.
Information posted on this website is provided for informational purposes only and is not intended to substitute for your individual legal or medical needs. Visitors to this website should seek the counsel of their own licensed, professional legal and medical healthcare providers regarding their own specific, personal needs.
Updated 04.03.13