BCBS denied appeal. What next?

I have BCBS of California PPO plan with an out of network deductible of $1k.

Last year they had no problem covering my individual therapy sessions.

This year, I started going to group therapy and individual on the same day. There are two different codes for the group and individual therapy. For some reason, because it’s on the same day, only one of the sessions is counted towards my OOP expenses (the significantly cheaper one, of course). If I were to do them on different days, both would count.

I only started going to therapy because I spoke to a representative and was told I’d be reimbursed. I’ve spent more than $8k on therapy this year and now I’m not going to be reimbursed because of something I had no idea about.

I filed an appeal because it seemed to be a system error that it’s unable to differentiate the two services. I received a denial letter with some generic language that doesn’t seem relevant to my claim about how they will only cover a certain percentage of OOP expenses.

I know this is a unique situation, but does this sound right to you? I hope to speak to the grievance coordinator tomorrow, and I plan to escalate this, but I’m not sure what the next steps are. Thanks all for reading.

submitted by /u/Valuable_Bat_4389
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