Insurance Voiding Prior Authorization Requests

For the last 5 years I have been self submitting prior authorization requests for medically necessary out of network services with a specialist DO for my medically complex children. The insurance is NYS CHIP. Through NYS external appeal process awarded medical necessity for these OON services.

As of January 2023 my health insurance has been voiding my prior authorization requests upon submission. No denial letter. No communication whatsoever in response to submission.

In the past NYS DFS has ordered my insurance to process the prior authorization. I filed a compliant with NYS DFS about insurances new tactic of completely ignoring me, DFS said it was a DOH problem. I filed a complaint with DOH who said there’s nothing they can do.

I’ve contacted my insurance multiple times. The last time I called the rep told me it’s my providers fault for refusing to contract with them and they will only process authorization requests submitted by the provider even though NYS external appeals awarded me medical necessity. How is this legal? The federal affordable care act protects my right to see OON providers for medically necessary specialty services.

I’m at a loss. Who can I complain to? NYS Attorney General? Try NYS DFS again? Is there a federal body that enforces ACA?

I have a year and a half of claims worth 17K+ at this point. I have to get someone to look at this. My kids need these services and as Medicaid recipients we cannot afford to continue care without reimbursement.

submitted by /u/Lazy_Contact_6315
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