Doc vs. BCBS question

I currently have BCBS Blue Choice POS. My question is has anyone every gotten anything in writing from the ins. co about how they say you have to see a PCP for 12 consecutive months but don't have to see the them every month. I am back to square one. I decided not to go to Yps. because by hubby really asked not to go that far. So I am back to have the surgery at Borgess. The letter from my PCP says he has been working with me since 11/05 I thought that would be good enough. I went to the my PCP in 11/05, 2/05 and every months since 4/05 I have a letter from a neuro-surgeon stating I need to get the surgery done. Does anyone have any other suggestions? Becky

Becky, I for one do not have any written critera from BCBS but you can go to their website to obtain the written criteria that is recommended for WLS. I think if the letter from your PCP spelled out the routine that you followed when going to him for weightloss then that would be acceptable. Does the letter specified the monthly visits to the PCP? I do know that sometimes they deny you just because something small is omitted and then when you resend it, they approve you. Do not give up. Ask Borgess what you need to get the ball going again. Take care, Janice

Call your insurance company. They will tell you the criteria over the phone. When they get to the part about the 12 month requirement, ask them SPECIFICALLY if that means that you have to be at the doctor's office every single month for 12 months in a row, or if several visits throughout a 12 month time period would fulfil the requirement. Then ask them to put it in writing or send you a copy of that criteria. That's what I did. My surgeon's office was telling me that BCBS required 12 monthly visits. But when I called BCBS (twice) and asked them specifically what the criteria stated, I found out that my 3 appointments within a 12 month period did the trick. I've kept really good records on those conversations. Date and time of the call, which number I dials, who I spoke to and recorded as much of the conversation in writing as I could (exact quotes and such). If I end up getting denied for coverage, I'm told that my notes from these phone calls can help with an appeal. Good luck! Pam

Thanks for the info Pam. I did call BCBS 2 times and they told me the same thing twice. I do need it in writing in order for Borgess to go ahead with the surgery. Nov. will be my 12th month so I am pushing really hard to get this loose ends wrapped up. Borgess wants to wait until April because then I will have documentation every month. I will call BCBS tomorrow to see if they will give something in writing. Thanks again Becky