No Pre Authorization? Blue Cross PPO

Thank you all for your replies!

I would double check on that yourself with the insurance company directly (before surgery).  All plans are different, especially if the employer is self-insured, but I have had two different BCBS PPO plans and both did pre-authorizations.  One even had a penalty for NOT getting a procedure authorized first.

Lora

I have Blue Cross PPO.  The surgeon's office did submit for approval and I received a copy of the approval letter from BCBS.

 

The PPO doesn't require a referral.  I think that's two different things.

 

The big things, as mentioned above, it to make sure bariatric surgery (and what types) are part of your policy, etc.  I called and had them email me a copy.  I gave a copy to my NP at the first visit.

 

good luck!!

Call BCBS or get on the website and look up the criteria. BCBS does what is called a predetermination, but you need to know the criteria before you start having your surgeon's office begin the process.

I have BCBS PPO of IL. 

CALL THEM they are very informative. I met the BMI requirement and they verbally said there shouldn't be any issues. HOWEVER I did have to have a psych eval and nut eval BEFORE they would approve it. They got rid of the 3-6 month diet requirement. 

I got my letter stating that I was approved and granted up to 5 days stay. They tell you is takes up to 21-30 days, but my surgeon submitted 7/30 and I was approved 8/7.... so about a week. My surgery was Friday! 

Good luck!

You can call BCBS and ask them to send you the part of your policy that either covers or or says no.  I have BCBS of MI and that is what I did.  I had it in writing.  Thank goodness I did.  Two weeks after my RNY I got a bill for $52000 from them saying it was not covered but I had it in writing from them that it was.  They can send it to you in writing.  (I also use to work for an Insurance Company and we use to have to send them)

 

Good luck

You can call BCBS and ask them to send you the part of your policy that either covers or or says no.  I have BCBS of MI and that is what I did.  I had it in writing.  Thank goodness I did.  Two weeks after my RNY I got a bill for $52000 from them saying it was not covered but I had it in writing from them that it was.  They can send it to you in writing.  (I also use to work for an Insurance Company and we use to have to send them)

 

Good luck

Wow! That is steep. 

I am thinking I will call Blue Cross today to have them send me something in writing about their policy and if I am covered or how much is covered. I hope to have this ready for when it comes time to pay for the surgery. As long as I "stay in network", which means all hospitals and most physicians in Michigan, I should be ok.

I just got off the phone with Blue Cross, and she said as long as they use the primary diagnosis code for morbid obesity, the surgery would be covered. I had her send the benefits booklet to my stepmom where I can pick it up. It explains the rules and information specifically in the section that talks about Bariatrics. She was not able to send out a custom letter which proves that I have met the deductible, etc.