HOME » Utilization Review Overturns Experimental Claim Denial Case Study




Blue Shield of California initially denied this claim based on a determination that medical records had been requested but not received. After Convergent confirmed that this medical information had actually been submitted, received, and reviewed, Blue Shield advised that the services had been denied as experimental/investigational.

Convergent worked with its internal UR Department to review the denial and evaluate it further in terms of the nature of the treatment. Convergent’s UR Department obtained Blue Shield’s internal medical policy guidance in connection with the type of service in question, and incorporated this information into its review. Following this review, Convergent pursued an appeal with Blue Shield addressing the particular circumstances of this medical treatment, utilizing both the medical documentation that the review performed by Convergent’s UR Department, and contended that the claim should be covered even under the terms of Blue Shield’s own medical policy guidelines.

Blue Shield conducted an additional review and overturned the initial denial. Blue Shield subsequently issued payment in the amount of $76,216.08 after reprocessing the previously denied claim.