Rehabilitation Services Denial [NY-IHA ESSENTIAL 200-250]
Hello all, I recently moved back home to reduce expenses because I have not been able to work full-time due to Long Covid (and potentially fibromyalgia). I signed up for health insurance under the New York Marketplace for the Essential Plan and selected Independent Health (IHA). I selected IHA based on input from the local subreddit.
My Long Covid Doctor (Long Covid Clinic) sent a referral for Physical Therapy (PT) and Occupational Therapy (OT) for the following*:
Brain fog (ICD-10 R41.89)
Chronic pain syndrome (ICD-10 G89.4)
COVID-19 long hauler (ICD-10 U09.9)
Fibromyalgia (ICD-10 M79.7)
*I believe both referrals have the same details. I’m not sure where the PT one is. This is “public” information as my post/comment history is public (is it reddit after all).
As of right now, my first PT visit has been denied. The second PT visit has yet to been received. The third PT visit is today. Each visit without insurance is $195.00. I’m not able to afford that as I’m on the path to being homeless even with the reduce expenses of moving back home. This is not an exaggeration. I’ll be withdrawing my retirement by mid-September.
This week, I also had my first occupational therapy visit. The claim has yet to hit my insurance but OT and PT fall under the same category of services. I admit this is my fault for not reading the member contract, but it wasn’t available directly under my online account and I ignored the paper copy I had because I have hundreds of pieces of paper. within the last couple months New medical provider group loves paper. It’s annoying.
Rehabilitation Services from the Contact (Page 32)
We Cover inpatient Rehabilitation Services consisting of physical therapy, speech therapy and occupational therapy for 60 days per Plan Year. The visit applies to all therapies combined.
We Cover speech and physical therapy only when:
Such therapy is related to the treatment or diagnosis of Your illness or injury; 2. The therapy is ordered by a Physician; and 3. You have been hospitalized or have undergone surgery for such illness or injury.
Covered Rehabilitation Services must begin within six (6) months of the later to occur:
The date of the injury or illness that caused the need for the therapy; 2. The date You are discharged from a Hospital where surgical treatment was rendered; or 3. The date outpatient surgical care is rendered.
I believe this is care that is vital to me to help regain as much functionality as possible and PT/OT are required elements from this Long Covid Clinic. I believe they can be helpful, as PT in two sessions has helped me identified a ballpark figure of what triggers my symptoms in terms of heart rate. Symptoms are always present, but I have episodes and its helpful to learn what causes these and to help reduce them. Primary Care, Neurology, Long Covid, and other specialist I see don’t have the time commitment, environment, or function to aid in my recovery.
What are my next steps here? I do not have an EOB as these are unavailable due to a technical issues with no timeline to resolve the issue.
Is this an appeal? a Grievance? Utilization Review? I’m looking at the end of the PDF, where the types of reviews are located and I don’t think any fit. Ultimately the terms of the contract were decided upon the State of New York, as this is a NYS medical plan.
Contract, scroll down towards bottom and select Essential Plan 200-250. This is a PDF)
I’d appreciate any suggestions. I’ve had issues with insurance but nothing that was either “mission critical”, or it was and provider just didn’t bill me for it.
