Supposed clarification from SHBP

He is better for now.  It was actually his 3rd surgery:  1st ata day and a half, 2nd at 2 and a half and then Feb. 08.  He was born w/o a pulmonary artery and also has an artificial aortic valve and is on blood thinners.

Sorry, I don't read it differently.  That sounds like a standard answer from a customer service rep at the SHBP...the script if you will. 

The understanding I had of the UHC process was using the Optimum as the case management/utilization review was in the contract between UHC and SHBP (a customer svc rep would have no knowledge of this).  People who have UHC who are not State of GA employees do not necessarily have to use Optimum services.

As for them accepting work you may have done prior to January 1st, they probably will.  A while back, while still trying to make the decision, I spoke with Optimum.  You'll still have to be assigned a case manager, but they may accept stuff done prior to the insurance kicking in.  The Optimum case manager is supposed to work with you to tell you which hoops to jump thru at what point in time.

Personally, I wasn't willing to take the chance that they wouldn't accept my previous stuff and went with Cigna.  According to the surgeon's office, we should be able to submit in January.  The worst that will happen is Cigna will send me back for 2 more "consecutive" monthly visits and a March re-submit.

Good luck to you!
Elli

I  Choose and called UHC HRA of ga. They told me I needed 3 months of supervised weight loss diets  from my dr. They will not accept weigh****chers, dietichans , nutritionist ONLY your PCP! So I started back in October. I clairified to my PCP to write specific detail on wh at I was doing in trying to lose weight. So I have a Sleep test coming up on Sunday. I am taking Metformin, eating less calories increasing fiber. Each attempt must be documented and weigh must be written exclusively in the Dr's notes. YOU have to be at least 100lbs over weight  and think that's it. I'm going to call back Monday just to double check .

Now that sounds just a bit "fishy" since everybody who called UHC during open enrollment was been told 6 months of diet with your PCP and 6 months of what they referred to as "behavior counseling" which, generally speaking, would be with a nutritionist.

Good luck!

Is your UHC with State of GA?  They told me 6 mos supervised diet anc nutritional counselling and Pscch approval.  They also said you can't start until the benefits change in January. Double check if you're a state employee.

Hey hey that's what they toldl me then .......... But today it's a whole different story. I called to dau jsut to check on things especially the appela that I made this July 2008. I never did get a response but they would consider it but a s of 2007-2008 it was excluded benefit. Anyway the rep had me on hold for about 15-20 minutes just to find a script and read to me abou the 6 months of PCP supervised diet (check, I don't know if the months can be concurrent or not) , 6 months of supervised diet with nuritinal counseling and psych eval for 6 months. This way too much junk to have I'm going to get iot together. She also told me that i had to wait for Jan 1 to get more info. I just could not understand that. Come on we have only weeks before Jan 1st or 2nd so why don't they know anything. That's one thing that really p's me off is when people try to conseal the truth. Just  don't try pee on me and tell me it's raining . Heck know I can't go for  that. So I'm going to call everyday for the month of December 2008 and maybe January  and write down names waste their time and doucument everytheing Staste health has one more letter coming their way from me. Also she state they will have these specal nurses that we will have to talk to in refernce to WLS. WOW what will they think of next .

I'm sorry you're having such a bad time. The Cigna reps seen better. They have always been very informative and seem to know what they're talking about.

I called UHC before choosing a plan and they didn't seem to have a clue, which is why I chose Cigna in the first place. 

I hope they are still as nice after the switch is official 1-1-09.  

Look on the bright side, at least the insurance will cover wls now!!! Whatever you have to go through to get there, just do it. It will be worth all the work.

I figure it won't do a lot of good calling and asking any more questions, since I don't even have the Cigna coverage yet.

My main concern now is finding someone who will do the DS surgery in GA.

I really don't have the time or energy, or desire to fight the insurance company about this surgery. It's stressful enough as it is. So, I'm developing a back-up plan (out of state surgery) just in case.

The 6 mos diet does have to be 6 consecutive months, You have to visit the Dr at least 1x per mo. The Dr. has to record your weight, height, bmi, type of diet therapy, and type of exercise. if all of this is not documented, it will not be approved.

Thanks I have informed my Dr she will ammend heer notes so they are more detailed. I don't mind. Ive seen the nutrionist (May) once so I have to make an appointment soon like tonight LOL. However I did see one at Rockdale hospital about 3 or 4 years ago. you think I could use that as a month too?

I don't know. I'd check with the insurance company and see.

Okay I lied I actually called twice today one to SHBP and the UHC. I asked why is 6 months of behavioral counseling with a psychologist necessary. Most People who have substance abuse or major depression have op session to this extent and further more what happens if I do have a mental crisis during the same year that is not associated to the 6 months WLS? I guess I would have maxed out my allotted funds in mental health. Anyway it's ridiculous. And plus WLS associated with a disorder is considered to a mental illness not WLS or treatment of obesity. According to the Diagnosis for mental health web site and books you would have to meet certain criteria to have an eating disorder if that's what they are trying to call it. I don't get it. I can understand having a mental evaluation but 6 months of behavioral counseling is crazy. What would be the reason or out come? Nothing will change unless you have other issues that came up during a psychosocial evaluation. They really have a dufus that is adding unnecessary criteria to our list to get approved.  Will our insurance pay for such a thing? Or will it be an out of pocket expense? I think need to work on the letter.SHBP  also assumes that obesity is a mental issue verses a hormonal, hereditary, or medical issue.