Legal Appeal – “Minnesota Department of Human Services”

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Monday, July 27, 2015

Ombudsman for the State Managed Health Care Programs
Minnesota Department of Human Services
PO Box 64249
St. Paul, MN 55164-0249

Cc: Appeals Office
Minnesota Department of Human Services
PO Box 64941
St. Paul, MN 55164-0941

To Whom It May Concern:

My name is Jane Doe and I am writing to request your assistance regarding the denial of a final appeal I submitted to my health insurance company to pay a number of different claims I incurred at the Health Care Center in Minnesotaville.

I am on a restricted insurance plan with my insurance company and in order for my insurance company to pay for any claims for services outside of those provided by my primary care provider , my primary doctor needs to submit a referral to the insurance company on my behalf.

From 01/01/2015 – 04/10/2015 (04/10/2015 being the date my primary care doctor changed to one closer to where I live) I was seen at the Health Care Center a few different times – one of which was for a complete sleep study and one for a sleep study follow-up. I was told my primary care provider needed to submit a referral to my insurance in order for them to pay the aforementioned claims.

I called my provider’s office and requested that they send the appropriate referrals to my insurance company. After a considerable length of time, I followed up with the insurance company to ensure the referrals were received; I was told they were not. I called my provider’s clinic a second time to make another request for the referrals to be sent. I proceeded to repeat this process approximately five more times because I was bounced back and forth from being told the referrals were sent to being told they were never received. As a result of the insurance company claiming they did not receive the referrals, they sent me notices stating the services listed in the claim notice were not paid for by my insurance. It was in response to those notices that I sent appeals to them requesting their reconsideration about paying the claims and the reason(s) why. In all of my appeals, I explained that my doctor’s clinic did indeed send the referrals and that the claims should be paid.

My insurance denied my final appeal about payment for these claims on 05/21/2015 and I am writing to your organization for assistance. I have enclosed the appropriate referrals from my primary care provider (or rather the doctor who was my primary care provider during the time-frame for the dates of service in question). I have also enclosed supporting documentation for your review.

In all, I am frustrated because, as a long-standing customer with my insurance company and as a patient of my primary healthcare clinic, I did everything I was supposed to do in the time I was supposed to do it to rectify the situation above. I am also frustrated and confused because my insurance company had already paid a claim with a date of service of 09/30/2014. That date falls in the time frame when all of my services would have needed a referral to be paid by insurance if not rendered by my primary care provider – just like the denied claims I’m writing you about. My insurance told me on 05/08/2015 that they paid the sleep center claim in question (claim #123456789) on 04/17/2015. How can my insurance pay that claim if it needs a referral and not pay these other claims if they need a referral too? It doesn’t make sense to me. If one claim has a referral, then any claim with the same service and/or provider that come after it should have a referral as well.

So, despite my best efforts, a gap was left somewhere in the process of fixing this, which resulted in my writing to you today.

Thank you for your prompt assistance in this matter. I look forward to your written response and/or phone call of acknowledgement.

Sincerely,

Jane Doe
Enclosure