Claim denied because referral came from OB/GYN, not PCP

[sfoomato]

What is the name of your state (only U.S. law)? New Jersey

At my annual check-up with my OB/GYN, I mentioned I had found some breast lumps and skin changes, she sent me for imaging, which showed a couple of cysts in my breasts. She then gave me a referral to see a breast specialist about the cysts and skin changes. I went to the appointment with the breast specialist. Later, I received notification from my health insurance company that coverage for the breast specialist claim was denied because I didn't get a referral from my PCP (my OB/GYN is not my PCP.) Is there anything I can do to get this claim fully or partially covered?

 

[cbg]

What does your insurance policy say with regards to referrals?

 

[sfoomato]

What does your insurance policy say with regards to referrals?

It says specialist visits require a referral from the assigned PCP.

 

[cbg]

Then I would say you're out of luck.

You can try appealing the decision, and probably should. But you have no legal grounds on which to fight the decision - it will be up to them if they want to offer a good will gesture and pay some or all of it, or not.

 

[sfoomato]

Yes, i appealed - their decision stands.

 

[cbg]

Then there's nowhere else to go with this. If the policy states (as most such policies do) that referrals have to be through the PCP, then the referrals have to be through the PCP.

That's all she wrote.

 

[sfoomato]

OK, thank you for your responses.