CIGNA Difficult Insurance Person in my Surgeon's Office

[Andrew0929 1,102]

The insurance person in my surgeon's office could be better. First, I had to decipher rule changes shown on the CIGNA website for her, and she agreed with me eventually but did so with a tude. A few weeks later, I received a mailing from her announcing the rule change I'd just explained to her. Still, no big deal - I'm sure they were just informing all CIGNA patients of the change.

My problem has to do with her interpretation of a different rule, which states that I need to see the NUT for "3 consecutive months (i.e.>= 89 days)". My issue is related to the fact that I went to the NUT on 6/27 and then on 8/2. The insurance person told me that due to no appointment in July, it's in violation of the "consecutive months" rule. I told her the appointments were 36 days apart, but she didn't give in.

I called CIGNA and had the customer service person speak directly to the people that approve/deny. They said this wasn't an issue as they don't specify the exact number of visits during that period, but only that there is continuous activity with a NUT during that period, which I thought was reasonable. They agreed that the rule wasn't meant to imply calendar months but instead a block of time.

I called the Surgeon's insurance person back and she said that in her experience they would deny this due to no activity in July. I told her what CIGNA said, but she said it doesn't matter and that the Medical Director that reviews this case will make that call. She said she'd send it in (after all other requirements and 2 more NUT visits completed), but didn't think it would be accepted. She said if we send it in and they don't like it, they could send it to the appeals process which could add an additional month. They may also just ask for one more nut visit and allow resubmitting in a week.

What do you think? Should I do the 5th Nut visit to be extra sure or try my luck and send it in with 4?

[RebecaSparkles 247]

Try your luck.