Dear Lauren, Amelia, Harry, et al:
Guess what I got in the mail yesterday? Yet ANOTHER Denial of Service from Dr. D at Comm'y 1st HMO. With much more information in a much smaller type font, so it still fits on one page.
The additional forms, however, were several more pages. This time I got the cover letter, and FOUR attachments, listed at the bottom of the cover letter (so convenient) as:
"Attachments: 1) Appeal of Adverse Determination Form, 2) Notice of Adverse Determination, 3) Request for Review by an IRO, 4) Appointment of Representative Statement."
The letter also states, "Please be informed that you have the right, at any time, to contatct the Texas Department of Insurance at 1(800) 252-3439."
In the body of the letter, it states (I find this amusing somehow):
"The Community First appeal process should be followed first unless your condition is life/limb threatening; in which case, you may request an immediate appeal to an independent review organization (IRO) and are not required to comply with CFHP's internal review process. Life threatening is defined by TIC Art 21.58A Sec 2, (12) as a disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted. The attached information also describes the process for obtaining an IRO."
I made several copies of this lovely missive and dropped off one with the infusion nurse at my neurologist's office, and he told me some pertinent information.
Evidently, since the cost has risen by more than 20 percent, and since the Medicare/Medicaid reimbursement schedule has not been decided upon or published, the other insurance carriers are stalling. He said that he is unable to infuse anyone at the moment, although the office is set up, the personnel are trained, and everything is in place, because they can't get authorizations for anyone. They are sending out a letter to all of the patients explaining that the delay may be lengthy. He told me that he could get Tysabri, but not give it to anyone yet.
I gather that some people somewhere are actually receiving infusions. Who are you and where do you live?
I am waiting to speak with an advocate at the NMSS office in Austin, as soon as she returns my call (she is out of the office right now I guess). IF we could have a lawyer call around and scare someone, maybe we could get some action....
ok, I am experimenting... I am trying to insert a pastel drawing of my eye that I did about fourteen years ago when I had optic neuritis. Did it work?