How do I go out of network/medical group?

My pcp's office seems to be giving me the run around and I can't find out what I need to do. I've posted on the other site as well.

Basically i need to go outside of the medical group (network?) to get a DS. How can I do this? My drs office seems to think that if they keep resubmitting the same referral it will get us somewhere. There is no one in the medical group that does the DS. Is a second opinion the best option? Or would they just not send me to a DS surgeon still?

I would email miss D.C and ask her. She will help you out.
You know where to find her

Your documentation from medical will have the instructions for how to appeal to go out of network. If you didn't keep those then please call your carrier and ask for the instructions.

Also request they have a member advocate contact you - it is their job to resolve complaints (that doesn't mean you always win, but they are there to help you through the process).

With limited network plans you are locked in however there are ways to work around it which may involve you choosing to go with the State plan and get out of the Anthem plan. But you have options and please call them and get the instructions if you don't have the paperwork.

if I understand you, there is no surgeon in your network that performs the DS and you need to go out of network to get a DS?  I have a HMO, for me I had to go out of network as there was no DS surgeon in network or in the next 3 states...every insurance/state has the requirments for pcp referrals for hmo's.  I requested my pcp to send a referral to the surgeon out of my network so I could get an appt. so that the out of network DS surgeon could request the DS.  It is none of your concern if there is no one in network to perform the surgey, if medically necessary, it is the responsibility of your insurance co to provide you competent surgeon in network if not then they have to let you go out of network.  In other words if there is no one in network to do the DS, they have to pay for you to go out of network if deemed medically necessary.

Thanks for this. I tried to get my dr to refer me to the surgeon outside the medical group but she said there is no way she can and even showed me how she does the referrals, which is a website she logs into, types in some stuff, and selects from a drop down menu 'bariatric surgeon' and only 1 comes up in the medical group. I am not sure how to go around this. I'm afraid if I just ask for a second opinion they will send me to another non-ds surgeon. Luckily, there is at least 1 DS surgeon in my state. Getting there seems nearly impossible tho lol

I had UHC.  I wrote them a letter.  There were two ways to approach it and both were applicable.  The first was that they had no surgeons that that did  the surgery that I needed in network and the second was that there were no DS surgeons with in X number of miles from my home.  (Your insurance company will have a set number of miles that they would expect you to travel.  Ask them that)   So  I wrote them a letter explaining these things and requesting that Dr. G be considered as "in network."  They wrote back and said "yes."

Was this a letter in regards to an appeal or just a letter? I will find out monday what the miles are.

Not an appeal.  This was my intial request.

My doctor is who does my referrals but I suppose maybe writing a letter to my insurance while they do this will help, especially since the dr isnt getting anywhere lol.  Did you have to write why you needed the DS vs the other in this letter ? Who did you send it to at the insurance? I am not sure who I should write a letter to. I am thinking the medical group since that is where it goes through?

Call and  get an address.  Ask them how you can go about getting a surgeon considered as "in network"  when there is no one currently on the list who does this surgery.