A family from Texas with health insurance coverage through BlueCross BlueShield of Illinois (BCBSIL) had their preteen child admitted to Change Academy at Lake of the Ozarks (CALO), a residential treatment center (RTC) in Lake Ozark, Missouri, from January 14, 2022, to June 29, 2022. Ultimately, due to lack of progress and escalating unsafe behaviors, the child was discharged from CALO and transferred to Lakeland Behavioral Health, an acute psychiatric hospital, for stabilization from June 30, 2022, to August 15, 2022. Finally, the child was then transferred to Village Behavioral Health (Village), an RTC in Louisville, Tennessee, from August 15, 2022, to May 17, 2023.
Upon admission to CALO, BCBSIL authorized the child’s residential care for about 30 days through February 18, 2022, at which point BCBSIL denied continued residential services as being not medically necessary. CALO then negotiated a “step-down” arrangement whereby BCBSIL would authorize and reimburse CALO for residential services at the rate of a partial hospitalization program (PHP). BCBSIL approved this step-down arrangement from February 19, 2022, to May 10, 2022, at which time BCBSIL denied continued PHP treatment as not medically necessary on the basis that care could instead be provided in an intensive outpatient program (IOP) from May 11, 2022, through discharge on June 29, 2022.
Upon the child’s admission to the Village, BCBSIL authorized residential services as the medically necessary level of care from August 15, 2022, to September 20, 2022, and then denied continued care (from September 21, 2022, through discharge on May 17, 2023) as being not medically necessary. This family reached out to the team at FixMyClaim for assistance pursuing reimbursement for all outstanding claims for their child’s treatment at CALO, and the Village. Our skilled appeals team prepared extensive appeals for both of these programs refuting all of BCBSIL’s denials.
For CALO, the appeal letter alone totaled 49 pages, and the complete level one appeal package including all supporting documentation totaled 1,667 pages. The level one appeal was submitted to BCBSIL on May 16, 2023, but the initial denial was upheld on July 5, 2023. The team at FixMyClaim then prepared an external or appeal request to the Illinois Department of Insurance on September 22, 2023, totaling 1,684 pages. Network Medical Review Co. (NMR) was assigned to examine the case and concluded on October 19, 2023, that continued residential treatment at CALO was medically necessary through discharge.
For the Village, the appeal letter totaled 89 pages, and the complete level one appeal package totaled 2,503 pages. The level one appeal was submitted to BCBSIL on June 14, 2023. When the team at FixMyClaim followed up on the outcome of the appeal on September 18, 2023, BCBSIL claimed to have no record of the appeal (despite having a confirmed delivery and return receipt), and requested that the appeal be resubmitted in its entirety. The team at FixMyClaim quickly prepared the appeal resubmission and shipped it out that same day. Upon review of the extensive level one appeal, BCBSIL concluded on October 4, 2023, that continued residential treatment was medically necessary through discharge and issued a full overturn of the initial adverse determination.
Village Appeal Overturn Letter
(FMC5-3557)