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

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

Published: Mar. 24, 2022Updated: Oct. 27, 2023

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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.

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Related Parent Questions

What is a treatment authorization request (TAR)?
Some medical, pharmacy, or dental services require a treatment authorization request (TAR) beforehand. Ask your provider whether a service will need a TAR and how long the authorization process could take.
What if there’s a problem with an insurance claim I submitted?
When you contact your health plan, always note the date of your call and get a name and a call reference number. Every call generates a reference, but you have to know to ask for it. Check the plan website to see if live chat or a customer service message center are options on your plan.
What should I put in my appeal for an insurance claim denial?
Appeals require some combination of these essential elements: initial evaluation for a plan of care and measurable goals, progress report, office visit or daily treatment notes, letter of medical necessity from your child’s therapist or physician, and summarizing cover letter.


Undivided Editorial TeamStaff

Reviewed by Undivided Editorial Team,

Contributors Leslie Lobel, Undivided Director of Health Plan Advocacy

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