Insurance Company Denial - what next?

What is the name of your state?What is the name of your state? Missouri

My husband received a diagnostic biopsy about a year ago to diagnose infertility. The doctor's office says they received pre-approval for the procedure but do not have documentation. The insurance plan states "Treatment of infertility is not covered....Except the diagnostic charges leading up to a diagnosis of infertility will be covered." However, the insurance company is refusing to pay for it. They have stated that although certain procedures for the diagnosis of infertility are covered, this biopsy was not one of them. When I asked them if I had ever been provided with this list of covered procedures they stated that 'no, that is an internal document.'

I have the option of filing a 2nd level grievance, any advice on how I should go about it? And how can I believe that a group of physicians hired by the insurance company to make a decision on my greivance will have my best interests in mind??

Thanks for any advice!

[porcelina68]

My advise would be, first of all, to call your customer service number - which should be on the back of your insurance ID card, and ask for a manager. If you are denied a manager, look in the phone book. That would list the switchboard number of the insurance company. Tell the operator that you were denied management and ask if they can help you get there. (I work on a switchboard at an insurance company, and we have lists of accounts, and who their managers are.) Assuming they get you to the manager - if that doesn't do any good, call back to the switchboard, and ask to be transferred to the office of the President, or the Chief Operating Officer of the company. You go as high up as you can. Explain your problem, and let them look into it for you.

Chances are if you go that high up, something will come of it. Good luck.