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I was denied service or payment restitution for a medical procedure. I underwent a colonoscopy and had a biopsy perfomed as well. The denial of payment was denied for the biopsy. I am a member of the city of New York Health Benefits Program. I have had the identical procedure performed theee previous time. I'm a confirmer suffere of ulcerative colitis and i'm in a very high risk group for colon cancer. the benefits have been paid without a hitch since 2001. Because of my age and the nature of the threat of ulcerative colitis I'm now advised by my GI specialist to undergo yearly colonoscopies to monitor my status. I have no idea how to even obtain dispute forms. The Empire Blue Cross site doesn't furnish a link to download dispute forms (no surprise there). They also failed to inform of denial of payment and yet have told me there is a 60 day period to dispute a denial of service. Yes, but what if the patient is NOT informed in writing of the denial of service. My request was pr

Submitted: 33 days ago.
Category: Legal
Value: $30
Status: CLOSED
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Optional Information

State/Country relating to Question: New York

Already Tried:
LEFT MESSAGE WITH AUTOMATED CONTACT SERVICE LETTING THEN KNOW i WOULD DISPUTE THEIR REFUSAL TO MAKE PAYMENT. I ASKED FOR INFORMATION ON HOW TO OBTAIN A DISPUTE FORM.

Accepted Answer

Dear Security,

 

ERISA requires that all plans such as these must provide you with the details of how to file appeals. If you contact them by phone and ask for the procedures and they don provide the information, then you can appeal by formal letter.

 

You need to give them at least one chance to respond to an appeal, but you may have to end up suing them.

 

In the past, appeals to a denial of benefits are included in the denial of benefits document /statement you receive in the mail.

 

If you did not receive a denial of benefits in the mail or you did and the appeal process was not included, then you will have to appeal by letter or file suit.

 

 

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Expert: BizMatters-law
Pos. Feedback: 100.0 %
Accepts: 
Answered: 10/19/2009

Attorney

JD

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