Blue Shield of California Health Claim Denials

Page Contents:

• Denied a Medical Treatment or Service? Attorney Scott Glovsky Can Help
• About Blue Shield of California
• About Blue Shield of California Promise Health Plan
• Blue Shield of California Violations
• Could Health Claim Denials Result in Additional Health Issues?
• What are the “Typical” Coverage Denials from Health Insurance Providers Like Blue Shield of California?
• Appealing a Blue Shield of California Denial of Coverage
• Summary of a Case That We Filed
• FAQs Regarding Blue Shield of California Coverage Denials
  • How Do I Fight a California Blue Shield Claim Denial? 
  • What Are My Rights When Blue Shield Denies My Claim?
  • What is the Internal Appeal Process for a California Blue Shield Claim Denial?
  • What if my plan refuses to pay for the care I think should be covered?
  • What is prior authorization?
  • What is the external review process?
  • How Do I File an External Review in California if Blue Shield Denies My Internal Appeal?
  • What types of denials can go to external review?
  • What Are the Time Limits for Appealing a Blue Shield Claim Denial?
  • How Can An Attorney Help if My Claim Has Been Denied by Blue Shield?
  • News Related to Blue Shield of California
  • How Attorney Scott Glovsky Can Help if You’ve Had a Coverage Denial

Being denied a medical treatment or service by your health insurance company can make you feel overwhelmed, unsure of where to turn. Turning to Scott Glovsky can change your story for the better. Scott is happiest when he is fighting for justice against big corporations who think they are untouchable. When a major corporation drags you to a low point in your life, leaving you injured, ignored, and anxious about the future, Scott can step in and make a positive difference. Scott Glovsky could be your last chance to get the justice you deserve—and he takes that responsibility seriously. Scott Glovsky might not look like a street fighter, but he can beat up your insurance company—just ask Anthem Blue Cross, Blue Shield of California, Health Net, Kaiser Permanente, Aetna, and United Healthcare.

Glovsky Lawsuit Against Blue Shield of California: Bad Faith, Unlawful Business Practices & Breach of Contract.

Blue Shield of California is a healthcare provider based in Oakland, California, and founded in 1939. The organization currently serves more than 4 million plan members and almost 65,000 physicians across the state of California. While Blue Shield was founded as a not-for-profit by the California Medical Association, it was stripped of its tax-exempt status by the California Franchise Tax Board in 2014.

When the company was created, it was known as California Physicians’ Service. In 1946 the company was one of the founders of the National Association of Blue Shield Plans, which later became Blue Cross and Blue Shield. Today, Blue Shield of California is an independent licensee of this national association. Blue Shield of California was the first in the nation to offer catastrophic coverage, in 1950.

Blue Shield was also the first healthcare company to provide coverage for a heart transplant in 1984. Blue Shield headed another first by offering online benefit and enrollment information in 1996, and by 2006, Blue Shield was recognized by NCQA as an “excellent plan” for service and quality. Blue Cross of California entered the Medicaid Market in 2015 Via Care 1^st Health Plan. In 2019, the plan was renamed Blue Shield of California Promise Health Plan.

There are currently 58,000 physicians and 340 hospitals across California served by Blue Shield of California provider network. Since 2010, Blue Shield has reduced patient care expenditures by $480 million, reduced hospital re-admissions by 13 percent, and cut the number of days patients stay in the hospital by 16 percent.

Blue Shield of California also collaborates with Manifest MedEx to advance secure health information sharing between providers, plans, and consumers. Like most insurance companies, Blue Shield of California sometimes denies legitimate claims. If you experience claim denial, you need serious help from an experienced health insurer denial lawyer like Scott Glovsky.

Owned by Blue Shield of California, Blue Shield of California Promise Health Plan (BSCPHP) is a managed care company that offers Medi-Cal plans for people in Los Angeles and San Diego counties. (Medi-Cal is the name for Medicaid in California.) Blue Shield of California purchased Care1st Health Plan in 2015 and renamed the company to Blue Shield of California Promise Health Plan in 2019. In Los Angeles county, BSCPHP partners with L.A. Care Health Plan in fourteen Community Resource Centers. In San Diego county, BSCPHP contracts with the Department of Health Care Services. You can learn about the Medi-Cal plans in BSCPHP’s Evidence of Coverage.

In August 2024, California’s Department of Managed Healthcare (DMHC) fined and took enforcement action against Blue Shield of California for billing its plan members for contraceptive healthcare services. Blue Shield paid a $250,000 fine and reimbursed $228,254 to 334 plan members who received incorrect contraceptive charges. In the state, health insurance companies must offer contraceptive devices, drugs and products that are FDA-approved free of charge to policyholders.

In December 2023, California’s DMHC fined Blue Shield of California $200,000 for mishandling provider claims resulting in policyholders not receiving the healthcare they needed. Although starting with thirteen provider claims for a member with gender dysphoria who received medical care from an out-of-network provider, the DMHC later discovered eight additional provider claims for other policyholders that weren’t paid within the acceptable thirty business day window. The DMHC also required Blue Shield to execute corrective actions to help prevent the issue from occurring again.

In August 2022, the DMHC gave Blue Shield (dba California Physician’s Service) a corrective action plan that required Blue Shield to adjust erroneous provider dispute resolution decisions. The insurer reprocessed about 1,300 provider claims and paid providers over $1.8 million in claims, interest and penalties.

Also in 2022, the DMHC overturned 55.9% of medically necessary Internal Medical Reviews (IMR) and Blue Shield reversed its prior denial in 18.8% of the appeals. In other words, policyholders who submitted external appeals (IMR) got the healthcare they needed in almost 75% of the cases. The DMHC also overturned 50% of Blue Shield of California Promise Health Plan’s medically necessary IMRs.

Read Our News Updates on Blue Shield of California

We have health insurance so we will be covered when we get sick. What happens when insurance companies reject legitimate claims? A recent survey reported by CBS News delved a little deeper into this issue, and the results might surprise you. In a full third of all cases in which legitimate healthcare claims were rejected, the patients reported a worsening of their conditions.  The study noted that, in many cases, the insurance appeals process simply does not work; less than half of those who appealed were successful, and half of those denied were turned down multiple times. The result of these denials includes patients who had to delay necessary treatments—or forgo the treatments altogether. Even when the insurer eventually provided coverage for the treatment, almost 33 percent reported worsening conditions.

In particular, patients who suffer from chronic illnesses find their health insurance almost “worthless” when essential treatments, prescribed by doctors, was withheld by insurance providers. The same study found that more than two-thirds of the patients surveyed believed insurance providers were “failing their customers.” More than 40 percent of patients who received a denial for a prescribed medication or treatment had to wait more than a month to receive a ruling on their initial appeal, with almost a third saying the process took longer than three months.  Insurers are, in effect, usurping the role of doctors, making determinations about what treatments and medications are medically necessary. Insurers use the following tactics to delay and deny necessary treatments:

• Insurers require prior authorization before payment for a procedure or medication is approved.
• Medications are “tiered,” then insurers refuse to pay for the top tier medications.
• Step therapy is used for medications and treatments, requiring patients to try a series of less expensive drugs or treatments before approving the initial drug or treatment prescribed by the doctor.
• Pharmacists—but not patients—are told the insurer will only pay for less expensive drugs in the same class, even when those drugs may have a different chemical structure.

Insurance companies like Blue Shield of California often come up with a variety of reasons to deny a treatment or a claim. Unfortunately, the primary reason for denial of claims is usually profit; insurance companies increase their profits by denying any claim they consider “questionable.” The most common reasons given by insurance companies like Blue Shield of California include:

• Coding errors for a diagnosis or procedure
• Omissions of diagnosis or procedure
• Blue Shield of California considers the treatment to be medically unnecessary
• The procedure in question is considered non-essential to the patient’s health, or elective
• Lack of prior authorization or pre-certification
• Incomplete insurance information
• Inaccurate insurance information
• Application filled out incorrectly, or incompletely
• In-network providers not used
• The filing time limit has passed
• Insufficient evidence of medical necessity
• Deductible not paid
• Co-pay not paid
• Patient portion not paid

Whatever reason you are given for denial of treatment, medication, or procedure your insurer must provide a written explanation that includes information on how the denial can be appealed. Download our eBook to learn about fighting health insurance denials. The state of California provides a method for appealing a denial; all insurers must maintain an internal appeals process. If the internal appeals process fails, there are other options for appealing a claim.

It can seem like an overwhelming task to not only be denied treatment or medication you need, but then to have to determine how the appeals process works, and to handle it on your own. A Blue Shield of California health insurer denial lawyer like Scott Glovsky has been helping people just like you for a very long time. Scott Glovsky can help you appeal your denial of coverage, whether it involves an outright denial of treatment or a refusal to reimburse a treatment you have already received. It can be significantly beneficial to your health and your future to have a highly skilled health insurance denial lawyer in your corner—someone who is truly watching your back and cares about your future.

As a Blue Shield of California plan member, you are guaranteed the right to file an appeal if you disagree with a denial of treatment, care, or prescription drug. The appeal must be filed within 60 calendar days from the date included on the denial letter. You must send a written appeal request which states the nature of the complaint. For a decision regarding services already received, Blue Shield of California has 60 calendar days to reconsider their initial decision. If Blue Shield finds in your favor, payment must be issued within 60 days of the date of your appeal request.

For a decision to authorize medical care, Blue Shield of California has up to thirty calendar days to make a decision but will attempt to make it sooner if your health condition is severe. If you or your doctor believes waiting for a standard appeal decision could seriously harm your health, you are allowed to ask for an expedited appeal.

If you are given an expedited appeal, you will receive a decision within 72 hours after receiving the request. If Blue Shield of California denies your medical appeal, your case will automatically be forwarded to an independent review, and if you receive a denial from this independent review, you are allowed to appeal to an administrative law judge if the value of your appeal meets the minimum requirements.

Unfortunately, the first appeal is rarely successful, since those who denied the claim the first time are generally the same as those who process the appeal. According to the Department of Managed Healthcare, of all medical necessity external appeals filed against Blue Shield of California in 2022, 74.7% of these policyholders ultimately received the medical care they appealed in the IMR. While you can certainly take your appeal to the next level for additional review, this may not be your best course of action. In some cases, it may make more sense to take your case directly to civil court, rather than attempting an independent review.

Your health insurance policy is a contract between you and your insurance company. If you are denied coverage, the courts may consider this a breach of contract on the part of your insurance company, ordering the insurance company to cover costs. An experienced Los Angeles Blue Shield of California health insurance denial lawyer like Scott Glovsky can evaluate your claim, helping you determine the way to proceed.

In addition to this example case summary, please view a full list of our results and client testimonials.

• We filed a case against Blue Shield of California for denying medically necessary emergency treatments. When our client got seriously ill with a strep infection while on a trip out of the country, Blue Shield initially lost and then denied his claim for coverage of his emergency treatment. This treatment included hospitalization, an ICU stay, and surgery to remove parts of his lungs. Blue Shield claimed that his treatment wasn’t an emergency, leaving our client with tens of thousands of dollars in medical bills. Our lawsuit alleges that Blue Shield has a system in place that is designed to save money by denying emergency care coverage to its members. It also alleges that Blue Shield doesn’t properly investigate claims before denying coverage and even incentivizes its medical reviewers to deny care. The lawsuit alleges that this conduct violates California law and is unfair, unlawful, and fraudulent. We are suing Blue Shield for breach of implied covenant of good faith and fair dealing, breach of contract, and violations of Business & Professions Code Section 17200.

If you have been denied healthcare coverage, you may have many questions, including:

How Do I Fight a California Blue Shield Claim Denial?

It can be frustrating and disheartening to have a medical claim denied by your insurer when your doctor believes that the procedure or treatment is the best option for your health and future. Yet insurers deny claims on a regular basis, typically when a treatment or procedure is expensive and the insurer does not want to pay. A Blue Shield claim denial could be the result of a simple error on the forms, a coding problem, or discrepancies in your information. These things can usually be fixed, and then the form is resubmitted. 

Other times, the denial letter you receive could state that the treatment or procedure was out of network, therefore not covered, or that it is a treatment or procedure that your policy states is not covered. Your insurer may also hide behind words like “not medically necessary,” “investigational,” or “experimental” to avoid paying for an expensive procedure or treatment. Read your denial letter carefully. If the issue is not something that can be easily remedied, then you have options. 

You can file an internal appeal, which essentially asks your insurer to reconsider the initial denial. It is always a good idea to include a letter from your doctor that details why the procedure or treatment is necessary and how your health will suffer if the claim is denied. If the internal appeal is unsuccessful, you can file an external appeal with a neutral third party. Whatever decision is reached, the insurance company must abide by the decision.

Always keep meticulous records, including copies of all correspondence, medical bills, and detailed notes from any phone calls. Even while you appeal, continue with your necessary treatments. Your plan cannot raise your rates or drop your coverage for appealing a denial. Consider legal help from an attorney like Scott Glovsky, who specializes in insurance denials and disputes. 

What Are My Rights When Blue Shield Denies My Claim?

While it may feel as though your insurance company holds all the cards, you do have rights. You have the right to appeal Blue Shield’s decision, first with an internal appeal, then with an external review. You have the right to emergency care without prior authorization, and you have the right to protection from surprise billing.  You have the right to receive copies of all documents, records, and information that are relevant to your claim from your insurer once you request them. You have the right to have an attorney advocate on your behalf, and you have the right to know the exact reason for any claim denial. 

What is the Internal Appeal Process for a California Blue Shield Claim Denial?

The internal appeal process begins when you submit a written request for an appeal after receiving a denial of claim letter. You will include your contact information, health insurance ID and claim number, along with a letter from your doctor detailing why the treatment or procedure is necessary, and all other supporting documentation. You will need to explain why you believe the denial of your claim was incurred, either on the form provided by Blue Shield or in a letter. 

Blue Shield will review the appeal, and for urgent cases, a faster review can be requested. Typically, you can mail the appeal to the address provided in your denial letter, or submit your documents through the company’s online portal. Providers disputing a claim on your behalf will use the Anthem “Dispute the Claim” option online. Blue Shield has a specific amount of time to review and respond to the internal appeal. If your internal appeal is denied, you have the right to an external appeal by an independent third party.

You can appeal your Blue Shield of California decision internally, asking that your insurer reconsider the denial. If your request is still denied, you can ask for an independent, external review to help resolve the dispute. If the external reviewer says the claim must be paid, your health plan will have to cover it.

Blue Shield of California may require that you obtain prior authorization or approval before you can obtain some healthcare services. If you obtained services without prior authorization—even if your doctor says those services are necessary—Blue Shield of California may refuse to pay for the treatment or service. It could be beneficial in such a case to have an experienced attorney help you receive reimbursement or payment for the treatment or service.

If Your Blue Shield of California appeal goes to the next stage—an external review—this review will either uphold the original decision or find in your favor. Blue Shield of California is required under California law to accept the decision of this external review.

How Do I File an External Review in California if Blue Shield Denies My Internal Appeal?

If you completed the internal appeal process and your claim was still denied, you can submit a written request for an external review, known as an Independent Medical Review (IMR). This request can be submitted to the California Department of Insurance (CDI) or the Department of Managed Health Care (DMHC), depending on your plan type. 

If your plan is regulated through DMHC, you can file a complaint through the online portal or by mail, stating the nature of your complaint. For CDI-regulated plans, you will file your complaint that involves a disagreement over coverage, exclusions, or limitations of your plan. The external reviewer will issue a final decision that either confirms Blue Shield’s denial of the claim or decides in your favor. The decision of the third party is legal and binding on your insurer. 

If you or your doctor believes that waiting for a standard external appeal decision could significantly harm your health, you can request an expedited appeal. Expedited reviews are available when there is an imminent and serious threat to your health, and are generally decided within 72 hours or less. 

Any type of denial, whether for a drug prescribed by your doctor, a treatment prescribed, an experimental treatment, or a test your doctor believes is medically necessary can go to an external review. 

What Are the Time Limits for Appealing a Blue Shield Claim Denial?

Your internal appeal must be filed within 60 calendar days from the date on your initial denial letter. You must send a written appeal request that states the nature of your complaint. For a decision regarding services already received, Blue Shield has 60 calendar days to reconsider its initial decision. If the internal appeal is decided in your favor, Blue Shield must issue payment within 60 days of the date of your appeal request. 

A decision to authorize medical care only gives Blue Shield up to 30 calendar days to make a decision, unless your issue is an emergency that could harm your health, then an expedited appeal is available. You have four months to file an external appeal after receiving the final denial notice from your internal appeal. A standard review decision is usually provided within 60 days from the date you filed the external appeal. 

How Can An Attorney Help if My Claim Has Been Denied by Blue Shield?

When you have an insurance denial attorney like Scott Glovsky, who has been fighting insurance companies for more than two decades, the outcome of your appeals is likely to be more positive. Your attorney will comprehensively investigate your claim denial, determining the specific reason. It could be a simple error, a dispute over medical necessity, or a more complex issue. 

Your attorney will handle the appeals process, preparing and filing all necessary documentation for your internal appeal and your external review, if necessary. Your attorney can easily interpret your policy, helping you understand whether your claim is covered, even when the language of the policy is unclear. Your attorney will handle all communications with Blue Shield, and if the appeals are unsuccessful, can represent you in settlement negotiations or at trial to fight for your rights and your future. Having an experienced insurance claim denial attorney from the Law Offices of Scott Glovsky ensures Blue Shield is not acting in bad faith. 

Blue Shield of California announced its Health Reimagined initiative in June of this year. The goal of Health Reimagined is to improve access to quality healthcare while making it more affordable. The program uses the latest innovations and technologies to transform healthcare. Blue Shield of California is a tax-paying nonprofit health plan, and has launched 20 pilot programs in four counties, from a customized virtual care system to an Apple Watch-enabled virtual assistant that helps physicians create electronic medical records with their voice. Blue Shield’s solutions cover holistic health, personal care, and high-tech, high touch.

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Attorney Scott Glovsky has significant experience helping people just like you who have been denied coverage for a necessary treatment or service. Like most people, you pay your health insurance premiums without fail, expecting in return that your insurer will take care of you when the time comes. Unfortunately, insurance companies like Blue Shield of California may engage in a variety of methods to deny coverage, thereby increasing their profits.

Scott Glovsky is the Blue Shield of California health insurance denial lawyer you need in your corner when it comes time to fight the insurance company. The Law Offices of Scott Glovsky are seasoned, with a successful track record going back over two decades. Many lives have been changed for the better by Scott Glovsky and his team, and yours can be changed as well. Scott will file and appeal through the internal processes of Blue Shield of California, create a case before the state’s review board, or take your case to court to enforce your policy.

If Blue Shield of California denied your health insurance claim, contact Scott Glovsky today to find out how we can help you get the treatment or service you need and deserve. Our goal is to ensure Blue Shield of California provides the coverage you were promised. Contact the Law Offices of Scott Glovsky today for the help you need and deserve.