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Wow, Thanks, XXXXX XXXXX excellent advice. I completely forgot about checking for denial of claims clause in the SPD. Thank you again. I expect that things will bog down if I have to actually file a claim, but let's see where this goes!
Hello ZDNLaw, I have follow up questions. After further review, I found the section in my summary plan description (SPD) that describes the prescription drug plan and the claims and appeals process. Both sections are quite detailed. I've reviewed the prescription plan and the prescription we are being denied is not on the list of excluded drugs. The provider claims that they are 'reviewing' our claim. This 'review' has been going on for a month and is an apparent attempt to avoid the claim denial and appeals process, since a claim denial requires a written explanation and the appeals process can be brought before a 3rd party arbritator.
So my questions are;
Should I file a complaint with NYS?
If I do, should I inform the Plan administrator that I am entering a complaint against them?
How effective is a single complaint? Are there any resources available to begin a class action suit? I suspect that the provider does this often, and most people just don't know their rights.
Thanks again. I will file and send a registered letter to my plan administrator. We've been told by our pharmacy that the insurer did deny the claim (I just found this out now), but not directly and not in writing. So we are certainly going to bring this to the attention of others. Are there any keywords that can be put on the letter envelope to the administrator that will get their attention?
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