Sure, it was a true emergency where his kidneys were shutting down. This was not a known or previous medical condition. Anthem originally denied the claim in August 2023, but the employee never received a notification about this denial. He is not aware of anything being mailed to his home.
The employee didn’t receive any bills from the hospital because he thought he had met his out-of-pocket maximum from other bills earlier in the year.
In January 2024, the hospital rebilled the insurance company after recoding the expenses. Again, the employee was unaware of this.
In May 2024, the hospital sent the employee a letter saying that the insurance company wasn’t paying anything. The employee reached out to ShareCare, a third-party administrator, for help. They communicated with him for the next several weeks. On July 11, 2024, ShareCare called to inform him that the bill was still incorrectly coded and needed to go back to the hospital.
On August 28, 2024, the employee received an email from ShareCare saying Anthem was still denying the claim due to it being deemed medically unnecessary. He needed to file a second-level appeal. The employee contacted the hospital for all his medical records related to the incident.
On September 5, 2024, the employee sent an email with all the medical records to the insurance company.
On October 1, 2024, he received a letter from corporate counsel indicating that the claim was denied and the ruling was final. This time, the reason for denial was that he was past the six-month mark since the first appeal was denied.
Now, the employee has been given three different reasons for the denial of his claim. He needs to figure out his next steps, whether that involves seeking help from a state-level organization or consulting an attorney.