Hi Rachel, thank you for the response.

I haven't made much progress. (and this is an overdue post, thank you Colleen for the earlier response--I have been working on both fronts in the meantime and was hoping to have more positive news to report)

Mayo precert/insurance says they can't make a precertification request due to their "billing code." (so how are exceptions ever considered? it can't be impossible...)

Carefirst (a DC area BCBS plan-- in network at Mayo etc.,) says Mayo must make a formal preauthorization request. Without an actual request they have no question to answer. I need Mayo to make a formal request. Not just call and ask questions.

Our BCBS case manager says they have no record of Mayo making a request. They do have a record re the PHP my teen did this spring (which was fully covered). Until Mayo makes a formal request, BCBS has nothing to "consider."

My guess is that Mayo bills this as predominantly medical (it's pain relating to a medical diagnosis). The program includes behavioral health components (group therapy etc). Because Mayo codes the 5+ hours of daily behavioral health as medical it doesn't fit the typical A, B, C process. But we have coverage for medical and behavioral health. And Mayo is in network (our week of visits in October cost me very little yea!)

If Mayo spoke with a BCBS "behavioral health" precert specialist or someone higher up they could solve it. Or at least get past "no" and submit the necessary "formal" precert request. Without a formal request, BCBS has nothing to evaluate.

I need Mayo to make a formal precert request. I can't do it. My son's case manager at BCBS can't do it. She said they can work this up the chain, but not without a formal request. And Mayo hasn't made a formal pre-cert request.

I need Mayo to not give up after the first phone call (which is why I'm spending my saturday reasearching and writing this). If the first phone call doesn't work, it needs to be elevated. My BCBS plan covers this but I can't make it happen. Without Mayo's formal precertification request, our case manager and her supervisor can't either.

We all know a single phone call won't resolve complex health coverage issues. Patients can't accept the first no as end of story. Patience, persistence, tenacity, and staying calm when you want to scream or throw your phone out the window. I think we can all relate.

I don't give up when advocating for my son (I even sued the school district this summer and got everything and more that he needed re his IEP--yea!!!). I don't give up at work either (I litigate $$$ cases for the US government (and for all Americans).

I don't give up until there is nothing more that can be done. (and it's horrible how much time it takes--as a single mom with a FT+ job, my time should be spent with my kid or taking care of myself, not getting more stressed over Catch-22 issues like this)

If i could do it, I am 90% sure I could do it. I could at least get beyond the first "no" and submit the required formal authorization request.

How do I get Mayo precert to get beyond the first phone call? How do I get them to submit a formal preauthorization request?

thanks,
Kari

PS. I found this online--if I can find this, there must be more where that came from (and this is public info, not behind a provider/insurance firewall):

Advance Benefit Determination
Providers may request an Advanced Benefit Determination (ABD) for certain services...
...providers may contact CareFirst’s provider services line to initiate an ABD request.
 Maryland: 800-854-5256
 Washington, D.C./Metropolitan Area: 202-488-4900