Referral and Authorization for MDIPA and Shady Grove

Anonymous
Hi, all. After an unsuccessful IUI last year with Shady Grove under BCBS, I'm trying to continue to IVF under MDIPA, but I've been stuck in this Kafka-esque hell with MDIPA.

First the referral, the process for which I got a ton of conflicting information from various MDIPA customer service reps. Finally, I picked it up from the PCP in person and walked it over to Shady Grove.

Now the authorization. I was told that the PCP needs to submit the request for authorization to MDIPA, and then MDIPA will pass along the authorization to Shady Grove. The PCP faxed it into MDIPA four times in the last two weeks, but MDIPA still doesn't have it in their records. I've been calling MDIPA several times a week, the PCP also talked to them directly, we confirmed the fax number several times, and the PCP's fax machine is working fine. All MDIPA says is that they don't know why they're not receiving it and that there's nothing I can do until they issue the authorization. In the mean time, I went ahead with my consultation, mock embryo transfer, and injection training (I'm 40 and really can't wait), for which Shady Grove charged me $600+. I'm hoping that MDIPA will reimburse me, since the authorization was requested (although not received) several weeks ago, but at this point, I wouldn't be surprised if they completely screw me.

What do I do? Can Shady Grove submit the request for authorization instead of the PCP? The financial counselors in the DC office said no, but I couldn't tell if that meant that they can't or that they won't. Should I call another Shady Grove office?

I hate insurance companies.
Anonymous
Can you have the PCP resend the authorization request? As many times as it takes? I am in the same boat, having switched from BCBS to MDIPA this year. It took only 4 days between when PCP sought authorization and when MDIPA provided authorization.
Anonymous
That's the thing - the PCP already faxed the form 4 times. They said there's no email address that they can send it to, and that the only mailing address is the general P.O. Box on the back of the card.
Anonymous
Can you get a copy of the authorization form and try faxing it from a different number (as many times as it takes)? Also, yes, if you're dealing with Cleveland in the DC office then try calling Rockville and talk to someone there. I found this hard to do because they kept pushing me back to Cleveland, but I found him to be no help at all.
Anonymous
None of the finance people in DC are worth their salt. I switched this month as well to MDIPA. First shady grove is supposed to submit the authorization not your pcp. Once your pcp submits the referral their job is done. I ended up calling the Rockville office. When you do I would put in a complaint about the DC finance team! I spoke with Cynthia in Rockville who I think is head of the HMO program. Someone else on here said Caitlin is really the best person. I would start with Caitlin and if need be call Cynthia. Don't bother with the DC finance team going forward.
Anonymous
Shady Grove submits the IVF authorization, not the PCP. The PCP submits the referral to Shady Grove and then that's all they do.

Anonymous
Thank you so much; this is really helpful. As I expected, this is the exact opposite of what the financial team at the DC Office told me, which was that they can't do anything until the PCP submits the request for authorization. Just left a message for Cynthia at the Rockville office and then heard from the PCP that MDIPA finally received the form and is now processing it. So at this point, I don't need to ask Shady Grove to submit the request, right? The form that the PCP submitted was dated Jan. 16, so I'm hoping that I'll be reimbursed for what I paid on Tuesday. . .

Again, I really appreciate everyone's help with this. Wish me luck!
Anonymous
Good luck. Insurance battles are the worst.
Anonymous
You want to be sure what the PCP submitted is the authorization and not the referral. My PCP submitted a referral - this allowed me up to 4 visits to see my RE at Shady Grove. It did not however authorize shady grove to treat me (think of it as start a treatment cycle). Shady Grove submitted the authoriation request to initiate a treatment cycle (for me that involved clomid+FSH+monitoring+timed intercourse). I started the treatment cycle before my authorization came through and signed a waiver stating that I was starting before authorization, but I still paid only my 50% portion of costs. By the time I received the letter in the mail with the authorization, I had already ovulated and so the treatment cycle (save beta test) was done. they did however date it from the date my insurance became active on 1/13/13.
Anonymous
PP, what did you have to do to get them to backdate the authorization to the effective date of your insurance coverage? I got mine, but it's effective on Jan. 30, which is a problem because my consult, for which I already paid $663.34, was on Jan. 29. Called MDIPA and, as always, was given the runaround by someone who obviously doesn't know anything about infertility benefits but finally said that the doctor needs to call them directly and request that the authorization backdated. Now I'm trying to convince my doctor to do that.

Ugh. I don't understand why I'm having such problems with MDIPA when everyone else seems to love them. Every single thing that could possible go wrong has, and I feel like the unluckiest wannabe-mom in the world. . .
Anonymous
Hmm - I didn't have to do anything. I think when they initially sent in the request it was dated for the 13th so even though they had to send it in twice because they just refaxed the original submission everything went smoothly. Your doctor shouldn't have a problem contacting them or writing a letter for you. Just ask them. Which doc are you seeing in DC?

I am a federal employee and I must say that when I call MDIPA on the phone, the reps on the federal account that I have spoken to have been extremely helpful and pleasant.
Anonymous
There seems to be an ongoing problem that some of the paperwork MDIPA sends out has the wrong fax number on it. You need to call, make sure you have a nice rep (many/most actually are), and have them find out what the right fax number is. I have no clue why this is an ongoing problem for them, but it is. MDIPA will backdate your coverage to the date your authorization request was submitted. i don't think they'll do it to before that.

For IVF, your RE should submit the authorization request. You just need a referral to your RE from your PCP.

When I first switched, I made the mistake of letting the financial people at my RE's office deal with MDIPA. With the exception of GW, I find the financial people at most RE's office will do the most minimal of follow up (i.e. keep faxing the same documentation over and over again without ever calling insurance company to find out why they haven't received it). It's annoying, but especially with the HMO coverage you need to pro-actively follow your case yourself.
Anonymous
We went through the same process, it was frustrating, but we finally got it done. Took two mths to get authorization though.

First, get the referal from your Primary Care Physician (PCP) and book an appointment with your doctor at Shady Grove. Book it atleast a mth in advance, so you have time to get the authorization as well.

Then call your insurance and ask to speak to someone regarding authorization. IMP: jot down this person's name, extension, and fax number.

Then call your PCP, and ask them to speak and ask for the same person when submitting requests for authorization. They're gonna ask your PCP a ton of questions, such as cause for referal, etc etc.

Finally, MDIPA will take all this info, and eventually give you an authorization. Then, you want to have this authorization faxed to Shady Grove.

Good luck!
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