Help! Insurance Issues!

Hi all. I am a little bummed. Yesterday my authorization said pending and today it said denied. So, I immediately called my surgeon's nurse, my insurance and my doctor and got the ball rolling. The nurse called the insurance and asked the problem. She tells me that they have denied me because I don't meet the criteria. But the problem is that I do meet the criteria. She knows I meet the criteria, so she put together an appeal letter and had it sent via fax by noon today. So now I am in "wait and see mode"... The nurse said she has never had a problem with Tricare and I am so worried that something is wrong... I was wondering if I should continue to call and ask what is going on, or if I should "cool it" for a few days, or what. Any advice would be a big help! Thanks, Carla

TRI CARE HAS BEEN ONE OF THE BEST FOR AUTHORIZING WLS, BUT LATELY I'VE BEGUN TO HEAR MURMURRINGS ON THE BOARDS THAT WLS IS BEING DENIED FOR THINGS AS REDICULOUS AS BEING 2 #s UNDER THE 100 # CRITERIA. BE CALM BUT CALL THE TRI CARE REFERRAL DEPARTMENT DIRECTLY. ASK WHAT SPECIFIC PART OF THEIR CRITERIA DID YOU NOT MEET. MAKE THEM JUSTIFY THEIR DECISION TO YOU. IF IT IS SOMETHING YOU CAN FIGHT, THEN ASK FOR THEIR DECISION & REASONING BEHIND THE DENIAL BE FORWARDED TO YOU & YOUR SURGEON IN WRITING, PREFERRABLY BY FAX. IN MOST CASES, IT IS EITHER 1 PROBLEM PERSON BEING A PAIN ... OR, JUST A MISTAKE. I JUST CALLED ON MY WLS AUTHORIZATION & WILL CALL BACK NEXT FRIDAY IF NOTHING IS RESOLVED WITHIN THIS WEEK. THEY WERE VERY NICE & ANSWERED ALL MY QUESTIONS. I HAD A REFERRAL DENIED ONLY ONE TIME & IT WAS A MAJOR MESS; MY FAMILY DOCTOR'S OFFICE COULDN'T EVEN GET IT FIXED. SO, I CALLED & CALMLY EXPLAINED THE MEDICAL SITUATION. THE GIRL I TALKED TO ACTUALLY SAID THAT SHE COULDN'T UNDERSTAND WHY THE NURSE HAD DENIED IT ... THAT THERE WAS NO LEGITIMATE REASON TO DENY IT. SHE CALLED ME BACK A COUPLE DAYS LATER & MY REFERRAL WAS AUTHORIZED WITHOUT ANY FURTHER TROUBLE. JUST BE SURE TO GET THE NAME OF THE PERSON YOU TALK TO & NOTE THE DAY YOU SPOKE WITH THEM. TRY TO CONTINUE TALKING TO THAT PARTICULAR PERSON ON FUTURE PHONE CALLS, LETTERS, FAXES, ETC. NO REASON TO"COOL IT"; GETTING THE FACTS IS ALWAYS THE WISE WAY TO GO! GOD BLESS DAWN & NICK

Hey Carla, first of all make sure that the referral from your PCM states "evaluate and treat". If you call Tricare they will tell you 800-444-5445. I have Tricare Prime and that was the biggest hold up I had, was the wording wasn't right on the initial referral. If you need anything please call me 843-532-4602, believe it or not I used to work for Tricare. Good Luck, Brittain