We have an ACA plan thru BCBSTX. I called prior to a visit to make sure my plan covered the procedure I was looking to get and make sure the doctor I was getting a referral for was in network. I was told yes to both and sent a letter stating such depending on medical necessity. They paid for my specialist visit.

My visit went well but the pre auth was denied for self referral. I called BCBSTX and again was told it is covered but I needed to appeal with more letters from my pcp and such. So, I went back and got letters from everyone including a visit to my neurologist that was out of pocket because the referral expired and I was on a time crunch. I resent it and then was finally told it was excluded and the appeal was closed due to error in opening. I asked for them to send a copy of the exclusion in my benefits and was told it isn’t specifically listed.

At a loss on what to do I reached out to BCBSTX via social media and had someone contact me. There is an exclusion even when deemed medically necessary which I was able to get a copy of. I could have avoided having very personal pictures (this was for a breast reduction) done twice, 3 trips to the doctors, numerous hours on the phone and paid for this out of pocket earlier in the year.

Back on track, I ask the rep to please note the 4 conversations I had with 4 different agents telling me this would be covered, how to appeal and what additional info is needed. He finds the conversations and agrees. Two days later he calls me back to tell me everything is reviewed and they will hold the decision that it will not be covered. He said we have to understand there is a learning curb with agents and apologized for the confusion. I asked who I am supposed to call to question my benefits and was told the 800 number I called is correct. So I called the correct number for benefits and was told incorrectly 4 times, went out of my way for additional info and paid several hundred dollars to be told oops. Also, they will not refund me for the visits.

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What do I do? This should have never happened. Do I report to the doi or just let it slide? This was a huge, humiliating thing. Not to mention I’m still in pain because I put the surgery off waiting on insurance to come back.

submitted by /u/PartlyCloudyTomorrow
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