Denied for Something my Plan Doesn’t Require

Just looking for recommendations on how to approach this for myself and to advocate to make things better for my colleagues…

Here’s the situation – I have a employer plan via Anthem BCBS Colorado. This same plan is also used by other employers, for state employees. We are public higher education and each school has their own contracts with Anthem. Many of our plans are similar but definitely not the same. However, our member IDs can start with the same letters even though we are at different employers.

I have had to go to physical therapy and did this last year with the same plan without issues. The PT clinic let me know they have been having so many consistent issues in 2024 specifically with people with my plan that they won’t go through our insurance anymore. However, they are physically near a school I don’t work for. So while my member ID and their member ID starts with the same 3 letters, it’s not the same plan.

At the same time a colleague of mine, who is in the same plan, has also been having issues getting physical therapy claims to go through properly.

It finally happened to me. I convinced the clinic to submit the claims for my visits so I could try to advocate/help with this. Out of the 3 claims submitted so far, 2 went through as expected and 1 was denied. The denied one had the same codes as one of the approved ones. The reason for denial was that a prior authorization was needed. However, a prior authorization actually isn’t needed and this was confirmed by Anthem to me when I called. Anthem says they are going to have a review done on their side to adjust it like the one that was approved…

My colleague who is also going to PT at a different clinic, is having the same issue except all of her claims are being denied for no prior auth. Anthem and Carelon are going back and forth in this case where Anthem is saying no prior auth (as do our plan docs) and Carelon is saying a prior auth is needed. This is more than frustrating.

After hearing that this issue is so much larger than just myself and my colleague now I’m extra mad. This isn’t just one clinic being impacted – it’s many in a major metropolitan area. They are all upset about my plan and these claims.

To me this is an Anthem problem and it’s impacting our ability to get care. Myself and my colleague both had surgery and couldn’t get physical therapy in time due to these issues.

Other than micro-managing Anthem, what else could I do to try to get larger change or a spotlight on this? One of my concerns is a lot of folks who may be denied services due to Anthems shenanigans may not know how to navigate the system so they aren’t saying anything. I’m planning on going to my benefits folks to alert them of this situation as well.