Proof of authorization-HMO

[sherdoe]

What is the name of your state? Illinois
Hi, I am looking for some advice, I will keep descriptions generic for
simplicity sake.
My relative passed away during a back surgery on March 13, 2005.

She had a PCP at 'Medical Site A' who had sent her for many tests and to several specialists for pain care as well as pre-surgery care. This was all authorized.

She changed her site to 'Medical Site B' effective 3-1-2005. Her surgery
was performed with the hospital and specialist affiliated with this new site on March 8th which subsequently caused her death on March 13th.
The HMO refuses to pay, stating that she never selected a PCP at Medical Site B (they are staking claim against the estate). Since she is not living any longer, I do not know whether she selected one or not. It seems to me that if she changed her site, she probably DID select a PCP at the new site. At any rate, I have combed thru bills, paperwork, etc. and do not know where to turn with this.

I assume that I can try to appeal the insurance decision, and continue to look for the PCP authorization.

Does anyone else have any other ideas? Somehow I need to find the PCP that she selected at 'Medical Site B'.
THanks for any input!

 

[pojo2]

See if any of her Physicians have the change noted in their records.

Unfortunately many times people do NOT properly make these changes as they do not even know it is necessary.

 

[lkc15507]

What is the name of your state? Illinois
Hi, I am looking for some advice, I will keep descriptions generic for
simplicity sake.
My relative passed away during a back surgery on March 13, 2005.

She had a PCP at 'Medical Site A' who had sent her for many tests and to several specialists for pain care as well as pre-surgery care. This was all authorized.

She changed her site to 'Medical Site B' effective 3-1-2005. Her surgery
was performed with the hospital and specialist affiliated with this new site on March 8th which subsequently caused her death on March 13th.
The HMO refuses to pay, stating that she never selected a PCP at Medical Site B (they are staking claim against the estate). Since she is not living any longer, I do not know whether she selected one or not. It seems to me that if she changed her site, she probably DID select a PCP at the new site. At any rate, I have combed thru bills, paperwork, etc. and do not know where to turn with this.

I assume that I can try to appeal the insurance decision, and continue to look for the PCP authorization.

Does anyone else have any other ideas? Somehow I need to find the PCP that she selected at 'Medical Site B'.
THanks for any input!

Well, HMO's are an animal that I hate to address. My knowlege is not the greatest. But, from what I do know, I have to question what transpired with the change from Medical Site A to Medical Site B. Of primary importance would be whether Medical Site A and Medical Site B are both included in the HMO plan. I want to assume they are, yet the information in the post does not verify that assumption. Any additional information would help. Yet, for practical purposes, the HMO's plan should outline the specific criteria applicable and the appeals procedure. (Although I will not commit to this opinion without further info, if Medical Sites A and B are both part of the same HMO, the PCP choice should carry through to both sites.)