Help! My upcoming surgery is at risk due to insurance bureaucracy
Help, please! I'm stuck in the insurance bureaucracy swirl and it's putting my upcoming surgery at risk.
Insurance: Horizon BCBS Omnia NJ, a marketplace plan with no out of state/network benefits.
I need to have an MRA (it's like a MRI) as part of surgical planning for cancer treatment. I also have metal in my body (due to my cancer treatment) and there's only one facility in the tri-state area, if not the country, who can accommodate me but it's out of state. Evicore pre-approved the procedure and the facility because it's medically necessary but BCBS won't cover it because the facility is out of network and I don't have OON benefits. The facility submitted requests for a gap exemption and a single case agreement but Utilization Management denied both because BCBS does not have a contract with the provider under my plan so a one-off contract is not possible. Make it make sense.
I've been told to go to an in-network provider instead and spent 2 hours on the phone with Evicore calling facilities to no avail because no in-network provider exists. I also spent another 2 hours speaking to an on-shore BCBS agent who called both Utilization Management and Evicore. Utilization Management is now saying they don't get involved in single case agreements for out of network providers and that it's Evicore's responsibility. Evicore says it's Utilization Management. The agent agrees that something isn't right and isn't sure what to do but is looking into it further. When I ask another off-shore agent what my options if I can't go to this facility, I'm told to find an in-network provider, even though one doesn't exist.
Does anyone have any advice about what to do or know why it would be denied? I can't have surgery without this image and the self-pay rate is over $3K, and that's with a discount. It's insane.