Prior Authorization?
I broke down and called my insurance company to see if they will cover WLS and all they could tell me was that I needed a prior authorization. Is this normal? I have already made an appointment at a bariatric facility and I was told all I needed was a referral from my doctor which I obtained and I have an appointment in July for there. I have United Healthcare Community of Ohio. Any info would be great.
5'-8",HW That is exactly what I thought. The lady I spoke to did not give me any clear requirements just that I need a prior authorization but I have already gotten a referral for the WLP from my doctor. It just has me scratching my head because I held out in calling because I was scared of hearing the denial of the whole process. I guess maybe I should just call back and speak to a different agent? Surely they can tell me the process if my prior authorization does in fact go thru.
Hi Rachael! Here's what I know from having worked in insurance: If all she told you is that it needs prior auth, that implies that it is covered if it's determined to be medically necessary. Different insurance carriers have different criteria for this, and that is what you would need - their medical necessity criteria. Most likely, your doctor has dealt with United for years and will already have this information, or be able to get it easily. At minimum, they'll want documentation from your regular doctor(s) of your weight history, and any obesity-related conditions, such as diabetes, sleep apnea, etc. Some require a "more conservative attempt at weight loss" such as having tried Weigh****chers or Jenny Craig. They may require a bit of weight loss prior to approval (10% seems to be the norm), and some even require completion of a lengthy doctor-supervised program prior to surgery. It varies a lot, and can seem like a daunting process. My best advice is to be patient, but follow up on things if necessary. For example, when the surgeon requests your records from your other physicians, make sure he gets them in a reasonable amount of time....once everything is submitted to United, give them about 30 days to respond - any longer than that, and you may need to become the "squeaky wheel". It's not a breeze, but people that meet the requirements do eventually get approved...it's just a matter of jumping through all the hoops, lol! Best wishes to you in your journey!
Thank you so much for your reply! I guess the waiting game is killing me. I have gotten the referral and prior authorization so I guess now I just need to be patient. I have a BMI of 43 and the lady at the WLP said that my BMI alone qualified me but I think she meant to the program its self and not on the insurance part.. Does that sound right?
I am afraid that I may have to do the whole 6 month diet and that is kinda what I need to do. What exactly the requirements are. I guess I will let that program be the one to communicate to my insurance bc I never really get a clear answer in terms of requirements. It may be because all of this is "situational".. Im not really sure.. Anyway, thanks again.
No problem. Yes, the bariatric surgeon's requirements are usually much simpler, and they can tell you straightaway if you're a candidate for surgery. Getting insurance to cover it is the tricky part....offices usually have a specific person who deals with insurance approvals and filing, so just stay in communication with that person to keep things on track. Frustrating as it may be, at least you are headed in the right direction! Again, best of luck!
