A sales manager for a specific carrier told me never to underestimate the power of the appeal process. I took that to heart and started helping members submit grievances and appeals when they are warranted from what he said. I thought it would be best to share my success story to all of you.
When that person called me, I chastised him for not calling me first. But what can I do? Since he had documented their conservation with customer service, I helped him. We completed the simple claim form. After putting all the information, we mailed it in. Did you know that within a month, my client already got his reimbursement? That’s it; miracles do happen.
But, here’s what happened. I’ve got a volley of conflicting emails, and it was out of network. Also, there weren’t any diagnosis or billing codes on the claim, and they never respond to me at all. This is the time where I told my second client to draft an appeal letter. We’ve documented everything, and finally, we’ve got permission from customer A to use his story.
Forty-five days later, the court responded and said that since it has been more than 60 days from the original service, the appeal was denied. In simpler terms, they ignored the merits of an appeal. This decision was final unless the client wants to file a request outside the government contractor (Maximus).
Eventually, the client received a letter from Maximus. That time, I wasn’t hopeful. As you can see, there’s been an excuse after excuse, and we believe that the carrier would find another stupid reason to deny the claim. But we were wrong! Several weeks passed by, and the member got a letter saying it was a favorable decision on their end. There’s also a separate envelope containing a check for over $1700!