BCBS Watch what you say!!!!!

I have been researching how BCBS HMOI conducts their inquiries with the members of the group/plans. They actually have a 172 page policy manual on this: here's the link http://www.bcbsil.com/PDF/providermanual/hmo_policy_and_procedure.pdf When a member calls customers service regarding the status of their approval every single word you convey to the service rep is entered into their computers. They make comments on your tone of voice, complaint etc. I would advise anyone who is dealing with them to be cautious with what you say, document your words, person you spoke with and results. Ask for answers in writing. Ask them to be specific regarding their denials, including reasons, who conducted the review, qualifications of the review members, needed criteria to meet for WLS. And what your next step should be. If you find it difficult to get past the customer service liasons for answers,then contact your hr representative. Askthem to get the underwriters of your plan involved with the higher ups of BCBS to find these answers. They can invesitigate if your denied claim is substantiated and in your policy. If it isn't then someone is in trouble with the underwriters. Now this of course should be done when you think something is wrong with the way your claim is being handled. I am very concerned especially about the way in which HMOI members are being treated. It seems as though some insurers are slacking off again with the regulations set forth by the federal government on denial of medically necessary treatments. No one should play games with your life and or your health. It's the law. annonymous....

Barb. They print all of that out, and show it to the appeal department when you appeal. I called the other day to find out the status of my appeal, and the lady said "Well we had to print out EVERY time you called, and you called a lot." I am sure it did take them a while! I call every day. I want them to know that I will not go away. I am always pleasent, and document everything, everyday. I probably have more notes than they do! Melissa

I've had the same experience. When they called me to give the second denial I was pretty upset and started to cry a bit, told them they dont care and the woman hung up on me.

I hate to say it but my approval process with BCBS HMO IL was a piece of cake. Once I'd completed all of the pre-op testing, I wrote my own ltr. of medical necessity and had my doctor approve it and rewrite it on his own letterhead. It was one full page long and documented every single health concern, illness, malady and/or disease I'd had related to a 38 year history of morbid obesity. The only additional info. required by BCBS was a ltr. from my PCP stating I was drug and alcohol free. I was approved within a week of the submission of all documents. And, I was ready for a denial and a fight. I'd armed myself with all sorts of documentation, legal information, etc. I never once called them to discuss the process. I think a lot depends of the umbrella company that manages the individual policy. That or I was just plain lucky. I wish there was something I could do or say to help you out ~ feel free to get in touch if I can be of any assistance. Katie

They told me that the appeal process is worse at the beginning of the year, becuase that is when most policy's start over. When you appeal their decision, it is in a pile with all sorts of other kinds of medical procedures. They say that they just go in order by the date recieved, but they can take up to 60 days to reply back.