My friend has soonercare and they won’t run her claim for insulin pump supplies. Beccause they won’t approve or deny the claim, she can’t get financial assistance from the manufacturer. How can she get Soonercare to run the claim?
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I didn’t know it was even an option for insurance to not even run a claim. What reason did they give? The only thing I’m imagining - Soonercare is a Medicaid program: perhaps you exceed their income guidelines or there’s another reason you don’t qualify? Of course I hope that’s not the case but I’m just using my imagination here. Keep us posted!
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My friend has been in class all day so she hasn’t been able to give me too many details, I didn’t know it was possible to not run a claim either. If I find out more I will defintely update so folks have more info to work with.
@concernedfriend0102, SoonerCare is a program run by the State of Oklahoma, and from what I see, benefits are very limited and certain qualifying criteria must be met for many items of care.
One of the limits is “Medically necessary …”. For your friend to demonstrate that she “qualifies” for pump supplies. she should ask her prescribing physician to submit reasons why a pump is absolutely necessary for her to live with diabetes. That is my initial thought only and not legal advice. As an aside, I lived with my diabetes very successfully for over 47 years using only a vial of insulin, a syringe, and a needle.
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J @concernedfriend0102, nice of you to try to get answers for your friend. Soonercare is Oklahoma’s Medicaid program. Getting the government to do something for an individual is tough. First thing your friend needs to do is obtain proof the claim was submitted from the supplier. Once they have that or the claim is showing up as pending your fiend has to follow the soonercare program procedures for asking for assistance. If they have and have been told there’s nothing that can be done they can try asking again today. Sometimes another person will know something uncommon or knows about diabetes and are willing to dig a little deeper for an answer.
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Did your friend work with a pump rep to get started? That’s the route people typically take when getting medical devices, and the reps are very knowledgeable about submission requirements and working with various plans.
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PS - in the interest of planning financially for a new device, I’ve called “the company” to ask about the cost - my plan’s guidelines say patients are responsible for XX percent, so knowing XX percent of what? will help me budget for it before my doctor starts the process. But I’ve found the company could not or would not give pricing without an actual order (prescription). I wonder if your friend miscommunicated what she was trying to do and didn’t understand the process, and that’s the holdup? If she has not discussed with her doctor her desire to get a pump, she should start there.
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