Advice on getting a Benefit Exception from our healthcare insurer?

August 20, 2014 5:02 AM

Husband needs open heart surgery. Our preferred surgeon is not on our healthcare plan. We're going to request a benefit exception. We are in Washington state. We are on an individual plan, not with an employer. I called the insurer and requested a case worker. Any suggestions on my approach? Feeling overwhelmed already.

We are going to ask the cardiologist to write to the insurer and request a benefit exception to pay for our preferred surgeon, Dr Q. We want to use Dr Q for the surgery because 1. Cardiologist believes patient is at high risk for a catastrophic event. 2. Dr Q performed the patient's first open heart surgery, several years ago (paid by a different healthcare insurer). 3. His familiarity with the patient makes him the best choice for a successful surgery and avoidance of expensive complications.

And we still have to find out if Dr Q's hospital is covered. He works two hospitals, but he will only do this procedure at Hospital A. And we need to get a plan-approved anesthesiologist.

Yes, we will look into using a plan-approved surgeon, but I want to request the benefit exception and see what happens.

My throw-away email is [e-mail]

posted by anonymous to Health & Fitness (1 answer total)

One thought is to check out the rules of the appeals process so you can plan ahead what to do on that front if your request is denied.
posted by XMLicious at 5:11 AM on August 20, 2014