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Blue Shield Appeals Process

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These are easy to read and understand and are beautifully presented.

It is always a good idea to make sure you have all the basic data about the claims that were filed.
Ask your midwife for a copy of the spreadsheet with all the filed claims  You will need this to keep your sanity as it will help you to know which claims have been paid and how much was paid for each claim item.  Every claim item should include:

If you get right on the appeals process and respond as soon as you receive the first denial, you can just write a simple general appeals letter.  But there are some appeals deadlines, and you want to make sure that you specifically appeal each denied claim before that deadline passes.  So it might make sense to start with that detailed appeals letter:

Here is the comprehensive approach:

  1. Start with a detailed appeals letter
  2. Follow up with a phone call
  3. Send a comprehensive appeals letter, adding a line that you are following up on your previous letter of <date>, your phone calls of <dates>, and that if you do not receive a satisfactory response from them within four weeks, you will be filing a complaint with the Insurance Commissioner.
The Department of Managed Health Care (DMHC) oversees Blue Cross of California and Blue Shield of California PPO health plans. The California Department of Insurance oversees most other PPOs in California.

Initial Letter

Dear Review Board:

I am writing to appeal insurance claims that Blue Shield has denied; these are claims for care surrounding pregnancy and birth and for a newborn baby.  Attached please find a complete list of claim items that need to be reprocessed, allowed and paid.

My midwife says that in her experience, Blue Shield of California eventually covers all of the charges associated with her services at a homebirth. She says there is a typical demonstrable and unjust payment pattern: Blue Shield initially denies all but the basic fee for the birth "procedure", 59400 or 59409.

She reports that if she uses 59400, then Blue Shield denies everything else, claiming that it's all included in the "global routine OB care" code.  (Yes, Blue Shield uses this excuse to deny claims for home postpartum visits at 24 and 48 hours and all claims for newborn care, including lab fees for the Newborn Screen.  Everyone knows that 99% of birth attendants who file claims with this code make do not routinely make home visits in lieu of postpartum hospitalization and do not  routinely provide newborn care.)

My midwife says that if she uses 59409, then Blue Shield denies everything else, claiming that she filed the wrong code. In fact, 59409 is the code that best describes the basic service of a homebirth. Midwifery care for a homebirth is totally different from global routine OB care and is properly described using 59409 for the one hour around the time of birth and then separately detailing all the non-routine care provided to the mother and baby.

This non-routine care includes direct face-to-face contact with the laboring woman throughout labor, providing all of the hands-on assessment of maternal vital signs and fetal heartrate patterns as well as providing all of the comfort care for the laboring woman.  This non-routine care further includes three to six hours after the birth, which is universally recognized as the minimum time medically necessary for a woman to be cared for in the immediate postpartum recovery period.  This goes beyond the typical "global routine OB care" of extracting the placenta and suturing.

That is why 59409 is the proper code to describe the birth "procedure", and all the rest of the care provided is described precisely.

California law requires insurance companies to cover all medically necessary care during labor and birth and for 48 hours afterwards for both mother and baby.  All of these claims were medically necessary for the well being of mother and baby.

Ronnie Falcao, LM MS, was the only licensed provider involved in this birth, and no hospitalization was required.  There will not be any additional claims filed by another birth attendant or a hospital for charges related to this birth.

To date, Blue Shield of California has paid only $__________ to Veronica G. Falcao, LM MS, for the care provided to the mother, and $__________ for the care provided to the baby, and $_________ for the specialty supplies and rented equipment necessary to conduct a safe birth.

In the past year, Blue Shield of California has eventually paid all of the claims for births attended by Veronica Falcao, LM MS, but they have previously required multiple rounds of interaction with the member/subscriber, denying for various reasons. Then the member/subscriber has filed a complaint with the California Insurance Commissioner, and then Blue Shield of California has eventually paid all the claims.

You can look in your records for the details of these past cases. This pattern of denial of claims for medically necessary care around a homebirth is in violation of CA Health and Safety Code 1371.37(a) and (c).

If I have not received complete payment for these claims within two weeks, I will place a followup phone call, wait two more weeks, and then I will file a complaint with the California Insurance Commissioner regarding Blue Shield's violation of state law by engaging in an unfair payment pattern.

I look forward to a prompt and satisfactory resolution of this appeals process.

Phone Call

Wait a couple of weeks after sending the letter and then call them to ask for the status of your appeal.  Make a written record of this phone call., noting the name of every person you speak with and note the start time and every time you are put on hold or transferred to a new person or end the phone call.  Ask them if they have received your letter and whether a check for full reimbursement is on its way to you.  If they have not agreed to cover the claims in full, ask if they understand that they are in violation of CA Health and Safety Code 1371.37(a) and (c).  Ask to speak to a manager and explain that you have received a total reimbursement of only <however many> dollars from Blue Shield for all the care around pregnancy, labor and birth as well as care for the new baby.  You Tell them that if you do not receive a satisfactory response from them within two weeks, you will be filing a complaint with the Insurance Commissioner regarding their violation of state law.

You can argue point for point on individual claims.

Appeals Letter

Dear Review Board:

I am writing in reference to insurance claims surrounding my pregnancy and birth that Blue Shield has denied.

All of the claims for <baby> were denied.  These included well baby visits and time immediately after the birth that had she been born in the hospital would have been performed by a pediatrician or nursing staff.  The claims should not be considered included in the global obstetrical care because they were for care of the child, not the woman giving birth.

All claims for <mother> outside of the global obstetrical care were denied.  The care went beyond this code.  There were complications monitored during pre natal visits such as <list your complications here.>  Specifics can be found in the attached medical records.  Also, time during labor and delivery would be outside of this code.  In the hospital, monitoring during labor would have been performed by nursing staff and not the obstetrician.  Since this was not a hospital birth, the midwife performed monitoring outside of the global obstetrical care code.    Post-partum claims were also denied.

Licensed midwives are not contracted with Blue Shield, but are paid at in-network rates.  <Midwife> is a licensed midwife who provided this care.

Thank you for your time,

<Clever Mother>


CA Health and Safety Code 1371.37(a) and (c)

(a) A health care service plan is prohibited from engaging in an unfair payment pattern, as defined in this section.
(c) An "unfair payment pattern," as used in this section, means any of the following:
(1) Engaging in a demonstrable and unjust pattern, as defined by the department, of reviewing or processing complete and accurate claims that result in payment delays.
(2) Engaging in a demonstrable and unjust pattern, as defined by the department, of reducing the amount of payment or denying complete and accurate claims.

This Web page is referenced from another page containing related information about Money and Paperwork


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