Insurance Questions with Leslie Lobel, Director of Health Plan Advocacy Services

During our most recent Office Hours session — where you can drop in on Zoom every other Wednesday and have face-to-face time with specialists, providers, and Undivided team members — our Head of Health Plan Advocacy Services, Leslie Lobel, answered questions about insurance claims, coverage, denials, appeals, and more.

Q: Why are my claims being denied when they were processed earlier in the year?

A: This answer can be found in your Explanation of Benefits (EOB), which is a document the plan creates for every claim that is processed. Look for the reason code and Its corresponding explanation. Here are some possible reasons your claim was denied:

• Not all plan years coincide with the January to December calendar year. Your plan year could have rolled over, and now your claims are applying to your deductible.
• A pre-authorization is now needed for services that were initially allowed.
• The health plan may have added a new requirement for coding from the provider, who will need to revise their superbill.

Q: My plan has specifically excluded any coverage for an ongoing service that my child needs. What are my options?

A: You can investigate other funding sources (your school district, Regional Center, Medi-Cal) with that exclusion document in hand, or you can explore getting secondary coverage for your child that includes a benefit for that service.

Q: What can I do now that my health plan has denied my appeal?

A: The fine print in your health plan’s Adverse Determination letter will give you the specific options for a higher-level appeal. This may be with the Department of Insurance or the Department of Managed Health Care, or possibly an independent external review.