Should I file an external review after 1st appeal denied?
Hi! My 1st appeal was denied stating the provider is not in-network but the claim was processed at my in-network level of benefits based on maximum allowed amount. The maximum allowed amount is the max amount of reimbursement the claims administrator will allow for covered medical services under this plan. No payment will be made under this plan for any amounts in excess of max allowed.
Quick background..I had a 4 hour complex septoplasty reconstruction with an out of network plastic surgeon, hospital and anesthesia was covered. I knew ahead of time I would have to pay the surgeon $20K and anything inusrance reimburses is mine. I also knew I wouldn't be getting a lot back but took the chance. They reimbursed $2300 which I think is ridiculous.
Do I go straight to External Review? I know it's a long shot, but I have to try because I paid out of pocket. Or am I wasting my time? Any advice would be appreciated.
submitted by /u/Ill-Chard1283
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