I’m a 28-year-old woman in Washington state, working for a small private company. I have an employer-managed health plan through Allied Benefit, which I believe is administered by Allstate and uses the Aetna network. Compared to our old Premera plan, this new setup has been difficult to work with.
I’m scheduled for a basic women’s health preventative surgery in three weeks, and my plan initially pre-authorized it, which seemed like a positive sign. But now I’m finding out that they won’t cover this surgery; instead, they’re saying they only cover a different, less ideal option. So, I put together a thorough appeal explaining the medical necessity, the ACA’s recommendations, and more, hoping to get this covered.
Almost immediately, they replied:
“Your request does not qualify for Appeal review, at this time. Appeals are for adverse benefit determinations (after the claim has been processed). Sterilization is excluded as you have indicated, which the Plan cannot override. The CPT code you provided is not on the Healthcare Reform Grid so therefore would not qualify for coverage under the medical benefits section. Also, a prior authorization is not a guarantee of benefits.”
I’m confused by several things:
What is “The Healthcare Reform Grid” they mention? I can’t find info on that anywhere.
Why won’t they let me appeal before the procedure? Their rep even told me to send in an appeal by email.
I’d appreciate any insights on whether I’m missing something here or if there’s a way to push back.
Edit: The rep who advised me to file an appeal knew I hadn’t had the procedure yet. So, I’m really frustrated with how this was handled. Any advice would be greatly appreciated!
Healthcare reform here refers to the ACA (Affordable Care Act). Under ACA, plans only have to cover one type of procedure from each category, like birth control. It sounds like your plan covers either a tubal ligation or bilateral salpingectomy, and you’re seeking the one that’s not covered.
Since Allied is a TPA (third-party administrator) for a self-funded plan, your employer likely chooses which procedures are covered. Your best route here might be to talk to HR or check if it’s self-funded. If so, your employer decides coverage, and Allied is just enforcing it.
@Kit
Thanks for explaining. I had no idea my employer had a say in the procedure codes covered. I’ll definitely check with HR about whether this plan is self-funded. It’s just frustrating that Allied didn’t clarify this to begin with.
Sounds like they’re saying the procedure is specifically excluded in your SPD (Summary Plan Description). If it’s a self-funded plan, your employer controls what’s covered, and Allied just processes it. However, if they denied pre-authorization, that should be considered an adverse determination and eligible for appeal.
@Merritt
Thank you for this. It’s weird because Allied initially approved pre-authorization, saying it’s medically necessary. But now they’re rejecting coverage and won’t consider my appeal. I’ll follow up with HR to see if I can find more details in the SPD.
So it seems like you’re looking for a bisalp, and they only cover tubal ligation. ACA rules require one option from each birth control category to be covered, but that doesn’t mean all procedures in that category are included. You might be able to get the bisalp covered, but it may not be at no cost.
@Hollis
Yes, I’m hoping to get a bisalp covered. They sent me a pre-authorization letter agreeing on medical necessity, but now they say the code is excluded. It’s really confusing.