Question:
Where to begin if you have Tricare Prime?
Ms. Lopez said that Tricare will deny if there is a military base nearby doing the surgery. So where do you go to begin the process - your local PCP [I'm a retired dependent], contact the base doc's office directly, or some other route? All of the various posts have gotten a bit confusing I admit, and I'm not sure where is the best place to begin or what I can do to facillitate the whole process. Is there anyone out there who has used Tricare Prime who would be willing to walk me through the process, or just share their experience? I'd be totally grateful for any info that anyone would be willing to share. Thanks for all and God bless, Cas — Casca L. (posted on April 30, 2003)
April 30, 2003
This is what I had to do. 1. Get a referral from my PCP on base. I don't
usually go to the base to see the doctor, so I just made an appt. with
family practice, with the doctor to whom I was assigned. 2. Ask that doctor
for a referral for bariatric surgery. This is where it can get tricky.
Sometimes, they don't do the surgery at the base nearest you. In that case,
you will get a referral to a doctor out in town. OR, if they doctors are
deployed, or whatEVER, you can get a referral out in town. I had mine done
on base, and there was a HUGE wait list. 3. After you find out where you
are going, make an appt. Then you'll find out what you need to do next, in
terms of testing, ect... I have to say it was FAR easier to just wait and
have the surgery on the base. I didn't have to pay for a thing, and didn't
have to bother with tricare. It was all done for me, without having to
submit paperwork, call anyone, or worry about bills for uncovered things.
The waiting wasn't easy, but it was worth it. :)
— Diana L.
April 30, 2003
I just went through the process in San Diego. In order for Tricare to
cover the surgery....
1. See your primary care doc for a consult for bariatric surgery. In San
Diego, it has to go to the surgery department first, where they will send
on to Tricare Health Care Finders stating they do not perform this type of
surgery.
2. Tricare will then evaluate the referral and make sure you meet the
requirements. 200% of your ideal body weight (example if 130 was your
ideal you would weigh 260), or 100lbs overweight with a comorbidity
(diabetes Hypertension etc) Then after that, if all is good, you will get
a referal to a doc out in town.
Then, the doc out in town will take over. Find out if they do this surgery
at the base. (near by is considered a 50 mile radius I believe by Tricare)
If the base performing these is over 50 miles away, they should refer you
out in town. Be proactive, and see what providers for this surgery are
covered and accept Tricare. I chose to drive about 100 miles to a doc in
Orange California and it was wonderful. (Tricare doc too) Don't limit
yourself.
I hope this helps. I found the paperwork was the most time consuming, but
once my initial referral to go and see the bariatric surgeon was in, it was
a piece of cake. The Surgeon took over requesting the surgery and getting
it approved. Email if you have anything else I can help you with.
— dimpkd
April 30, 2003
First I want to say that Tricare Prime is the best insurance, and I thank
my husband who is retired, who served his time, and made it possible to
have Tricare Prime for our insurance carrier. Is your pcp in the Tricare
Prime network? You do not have to use the base, I live 35 miles from an
AirForce base and I never go to the base. If your pcp is in the Tricare
Prime network, and you feel good about him/her putting in a referral to see
a gastric bypass surgeon, then you can go to "find a doc" on this
web site and find a surgeon that excepts Tricare Prime, then go to your pcp
and if it is medically necessary, they can put in a referral for you, and
Tricare Prime will come back with an approval or they will need more
information. I have a list of things that goes on your referral on my
profile, please take a look. Hope this helps
— cindy
April 30, 2003
I also wanted to add that I have had a very good experience dealing with
Tricare Prime. I live on Ft. Polk and we have a surgeon here who does the
surgeries but I felt very uncomfortable having the surgery done at a
military hospital. Lucky for me, the surgeon deployed. So, I saw my PCP
who put in a referral for me to see a civilian surgeon. He submitted the
request to Tricare. 24 hours of receiving the request, they approved it!
Easy as pie! I had to have a psych consult and once my surgeon had the
approval and the okay from the psychologist, we set a date! I am having my
pre-op done on May 12th and surgery on May 19th. So, good luck to you.
Start with your PCP and it should be easy from there as long as you meet
the requirements.
— Tami H.
Click Here to Return