insurance hell from bcbsm ppo

I recieved a letter yesterday with an Anthem Blue Cross Blue Shield from lousville, ky letterhead which confused me because I have BCBSM PPO. Also the letter states that my surgical office needs to forward a 12 month weight loss history and a medical exam with evaluation. I called the number on the back of my card and asked to speak with a supervisor. I was told that the supervisors were on lunch and she would leave a message for them to get back with me in 24 hours. Meanwhile she tried to help me. She told me that the central office that works with Indiana is in ky and that is why I recieved the letter from there. (central office for BCbSM is in ky?). I asked her "Was there a change to the weight loss surgery requirements in January stating that 6 months of diet is needed and with a BMI over 50 it is waived?" She told me that she wasn't sure but her cheat sheet said that 12 months was needed. I was hoping for a letter stating that my weight loss history wasn't needed for a BMI of 57, but I was going to settle for one saying that I needed 6 months of weight loss supervision. I got one saying 12 months is needed!? I am very confused and frustrated. What can I do?

Hi Robyn.  Not sure what you can do but I may be able to help you understand the BCBS PPO thing. Anthem BCBS is actualy California BCBS but they changed their name to Anthem BC/BS.  In the case of BCBS they have something called reciprocity and what that basically means is all billing for providers not in CA are to bill their local BCBS and then that local BCBS seeks reimbursement from Anthem (or any other BCBS - for example if you have MIichigan BC/BS and need medical care while in another state such as Illinois the provider/doctor would bill the Illinois BC/BS, Illinois would pay the doc and then Illinois BC/BS would be reimbursed by MIichigan BC/BS) The reason they do this is becasue the local states know whqat the reasonable & customary fees are for their own state whereas CA (or anyother state for that matter) does not. So in your case it would be Indiana BC/BS paying your claims and then being reimbursed by Anthem. It sounds like Anthem has regional centers to handle their claims and so that is probably why you were sent to KY. OR it could be that the Indiana BC/BS claims offices are in KY. Either way Anthen BC/BS is California based and sells nationwide.  My employer also has Anthem BC/BS PPO, the corporate headquarters are based in St. Louis, MO. So there are no California ties to Anthem other than they were probably the best bidder for our contracted health care.  Also when I went to my doctor's office (just yesterday- which is the 1st time I used this insurance as I am a new hire) they told me they bill MI BC/BS not ANTHEM.. Years ago I used to run a doc's office insurance billing so I sort of undertand it all but it sure does get confusing these days with all the HMO's & PPO's.  Hope this helps.

All a cross the board for BCBS (any plan) is 6 months worth of diet attempts by a physician..if BMI is over 50 it is waived.  You need to call back and ask for a supervisor...people there dont know what  they are talking about.  Call back and eventually you will find one that knows what is current...Best wishes. SHannon

Thank you for the info Patt. Shannon, I was really hoping that my surgeon's office would be aware of this and be able to help me, but it didn't turn out that way. What should I say to the supervisor when I call? Should i say "Was there a change in January that states..?" or should I say "I know that there was a change in January that states..."

Ask them- "what is the criteria for WLS"  Let them know your BMI is over 50 and your documentation should be waived..a supervisor would know the rules....

I want to cry I called back and asked to speak with a super visor and I was told that I could not be put directly to a supervisor. She told me that she would have to leave my name and # and that a supervisor would call me back in 24-48 hours. Why is it that I hear all of these great stories about how easy and fast BCBS MI approves, but everyone I talk to seems to know nothing about a change in criteria? I am so frustrated and mentally exhuasted.

UPDATE Shannon, I was looking over the documents that you sent me a while back showing that with a BMI greater than 50 the 6 month supervised wieght loss is waived. I always thought that i cannot use this to prove to the customer service rep because it says BCN and not BCBSM, but I scrolled all the way to the bottom and i see QUOTE "

I.      Effective Dates:

 

Policy updated: 09/11/02, 11/20/02, 02/09/04, 05/05/04, 06/15/05, 10/24/05, 07/01/06, 07/01/07, 9/1/07 (BCN) and 1/1/08 (BCBSM)

END QUOTE" Ha you see, it says BCBSM on it right there. How can i use this to my advantage?

Robyn- Great news!! See I knew it was right..and I am glad you got those documents- it said BCN but applies to all BCBS....good luck!! SHannon

((HUGS))  I know how frustrating all of this is - especially for you when so many of us are telling you one thing and you are either being told something else or they just plain don't know.  UGGH!  I was going to ask you to check on a rider since I know that things change with your insurance once you step out of your state, but Patt had that covered.  It is really great having so many knowledgeable people with the inside scoop here!!   You sure wouldn't get all that info from a dr's office.  I agree with Shannon too.   Go to the top.  I am sorry that they won't allow you to talk to them when YOU want.  Hopefully they return your call sooner than later.  ((HUGS))  I hope you get good news when they do call. Keep us updated!

I think I may have gotten to the source of my problem finally. My husband called the Ford UAW representative and she said that the # on the back of my card is incorrect and gave him a different # to call. The representative talked to me and verified that the # on the back of my card was wrong and said that she would mail correct id cards to me in 7 to 10 days. I then asked her what the criteria for weight loss surgery are and gave her the procedure # and diagnosis code. She told me that it was covered 100% for me, and as she read off the criteria to me, it matched exactly what everyone here has been telling me down to the BMI above 50 waiving supervised weight loss. I am waiting for the new cards and then I will bring them to my surgeon's office and give them the providor inquiry # that was provided to me by this woman. I wrote down her name, and I hope this is really as hopeful as it sounds. Thank you for all of your concerns and please keep me in your prayers.