I applied for a gap exception and got approved pre-procedure. Insurance has continued to deny my claim and appeals, making the procedure out of network now. Is this grounds to get third party help?

Back in April, I applied for a gap exception with my insurance. The representative looked at the terms of my policy, and didn’t see an issue. The gap exception was allowing a birth center to be in-network since there are none within 50 miles of my residence. Everything went pretty smoothly on the front end. I talked to the exception dept. All paperwork was filled out correctly with proper medical and tax IDs for the provider/birth center. I received an approval of the gap exception via mail with all the billing codes that would be allowed as part of the service. I thought, for sure, no detail was missed.

Fast forward to June. Baby was born and the birth center provided me with the invoice to give my insurance company. They processed everything almost everything as out of network or denied parts of the claim, so that won’t even go toward my OON deductible. The first time I called and talked to the Appeals Department, the rep told me there are two billing codes that “cancel each other out” if they are billed together. Essentially, only one can be billed. I send in an appeal. It is denied. Call the appeals dept. I finally talk to a manager within that department. He understands my whole situation after explaining it multiple times to other reps. It has been denied through his appeal because the admin dept is claiming that I needed a special referral for this. Not only does my insurance state no referrals are needed, a midwife isn’t considered a specialist.

I’m at a loss and I feel truly screwed over by insurance in this moment. Isn’t there an insurance agency in each state that reviews claims to help consumers? Would this be grounds for review?

submitted by /u/United-Grab107
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