Cheesecake

We received authoization to go to Shepherd Tues about 11:00 am. I think Blue Shield gave authorization for Shepherd but refused to pay any transportation expense. My wife and daughter and going with Brian Wed at 8:00 am. Blue Shield sent me a letter on why they refused the transportation expense. It wasn't much of an explanation.

1. The principle reason for the denial is that you do not meet the Blue
Shield criteria for approval
2. The clinical rationale for the denial is that specifically: (1) there is no
documentation leading to the conclusion that appropriate spinal rehab
services cannot be provided by one of Blue Shield's affiliated in state
network providers, and (2) once an approved CA facility is selected, a
clinical assessment will be made by both the current hospital facility
and the receiving facility to assist in Blue Shield's determination in the
most appropriate mode of transportation.
3. Because the information provided shows that you do not meet the
necessary criteria for approval, we are unable to comply with this
request.

Like I said this explanation didn't really satisfy me. Brian's insurance is a PPO plan so I don't understand the requirement to go to an " in state network provider ". Shepherd is a Blue Shield network hospital and the Blue Shield Evidence of Coverage says:
"Benefits are provided for (1) Medically Necessary ambulance services (surface or air) when used to transport a Person from place of illness or injury to the closest medical facility where appropriate treatment can be received, or (2) Medically Necessary ambulance transportation from one medical facility to another."

We doing #2 transport from one medical facility to another. I appealed the Blue Shield decision and they rejected the appeal. I'll pursue this after we get Brian into rehab at the Shepherd Center.

Roger