Contain Your Excitement – dealing with denied medical claims and prior authorizations

with 1 Comment

Are you ready to tackle a topic none of us want to deal with?  Me either, but this is definitely a topic you cannot run away from.  For if you do, you will be stuck with even more medical bills. For me, this in an endless source of frustration – am I the only one who yells at the phone because the computer can’t understand what your saying?? Even talking about it raises my blood pressure!  And you can plan on spending at least 30 minutes on the phone every time you have to call. However, all parents of chronically or critically ill children have to deal with insurance issues on a regular basis, so we may as well learn some ways to make this less frustrating.

So the question is, how can I get approval for medical procedures my child needs and how do I fight denied medical claims? I have a few suggestions.  First, get a case manager with your insurance company.  They may tell you at first they don’t have case managers. It took me searching for about a month before Anthem finally located the correct department and put me in touch with a case manager.  I’m pretty sure all insurance companies offer them.  If you have Anthem Blue Cross Blue Shield, here is the number to call to obtain a case manager:


If you have a different insurance company and you already have a case manager, please share that phone number in the comments so others can locate one as well.

A case manager can help you get medications, procedures, surgeries and doctor visits preapproved, even if they are out of network.  If your child has a rare condition and you have to travel out of town for their care often, this can be especially important.

Once you have a case manager, you want to keep them.  If you no longer need their service, they will close your case.  Then you need to start all over again if you need more help.  I have found it helpful to deal with the same case manager since they will be familiar with your child and know their needs.  One way you can do this is by asking questions each time they call.  If you keep having a need for them, they will keep your case open (hopefully). Each insurance company may be different, but at Anthem, the case managers are nurses.  So feel free to ask as many medical questions as you can.

Something to be aware of is the possibility to get blanket approval for an out of network facility.  My daughter is treated at Cincinnati Children’s Hospital which is out of network for our insurance. It took a lot of work, but with the help of my case manager, I was able to get an annual blanket coverage for 45 visits there.  This has been extremely helpful to not have to deal with it each time she has to go.  I was told this was not something they do, but I stuck with it long enough and provided enough information that they finally approved it.  Just know that may be an option for your insurance company as well, even if you’re told at first that it’s not.

 Every month, you probably get a stack of EOB’s (explanation of benefits).  When I receive mine, I make one stack of claims they paid and one of claims they denied.  Each denied claim, I appeal.  PLEASE do not accept the first denial of a claim – I see that as a starting point.  On the back of the EOB (or on your insurance company’s website) they provide instructions for appealing a claim. If you received a prior authorization number, you may be able to just call in and give them that number and ask to have it reprocessed.  If you didn’t have a prior authorization number, you will probably have to submit an appeal via the mail or online.  Don’t be afraid to combine appeals that are for the same provider to save time. 

An example of this is an appeal I made for claims from our local children’s hospital lab.  Even though the hospital is in network, the lab is not. I know, crazy right? Like I can choose where they send my daughter’s blood to get cross typed and matched for a blood transfusion.  So I appealed each lab charge and also requested that the lab be considered as in network for our policy. YES you can make requests like thatJ  I don’t know if their contract agreement changed or they honored my appeal, but the lab is now considered in network and all past claims were reprocessed and paid as well.

To review:
1. Get a Case Manager through your insurance company

2. Keep your case manager by asking questions

3. Blanket approvals for out of network facilities are possible

4. Appeal denied claims again and again if necessary


I hope this helps to make this process a little less frustrating (although anytime we have to deal with insurance it’s hard not to get frustrated! 

We are in this together,

Much Love,


One Response

  1. Angie
    | Reply

    Tyia-you are an amazing lady! Keep up the good fight for your daughter. I’m sure many people will be super informed and blessed by your knowledge on this one… stuff is THE PITS!!!!

Leave a Reply