Approval with Pacific Care HMO

My new insurance policy, Pacific Care of CA HMO, becomes effective on January 1st.  This new policy will cover WLS, and I already have an appointment with my doctor on January 2 to get my referral for surgery. She is super-supportive of my decision and is doing everything to help me be approved.  My question is: Has anyone RECENTLY been required to participate in a 6-month educational "coaching" call prior to being approved for surgery? I understand that the 1-hour coaching call is a new requirement for Pacific Care patients.  I already have 6months of  diet and exercise documented by my doctor. Was the six-month class waived or reduced for any reason?  Thanks in advance for your help!

Very nice.  The six month diet is usually met with the type of diet records you probably have.  You should be fine.   Best of luck and please keep us posted.

Hi there, I too have pacificare HMO and currently on this 6 month diet thing. I am pretty sure that any prior diets won't count- i have weekly appointments with my coach and we talk for like 25 min weekly. they send you a book and guidelines. it's kind of nice actually but this is 3rd month and i am ready to be done with it. i tried to get a referral from my PCP and they wouldn't even give me a referral to the surgeon until completing their diet. it's called healthy roads. anyway, best of luck to you.  jaime

Thanks for the info Jamie! The six months of diet was supervised by my doctor, is that what you're doing? How long do you have to do the healthy roads program?

Hi Moe, I guess it's doctor supervised. My PCP dosen't really know what they are doing and I have had to do all the investigating for myself. The PCP has to give the referral for the Healthy Roads program. The program is paid for by Pacificare since they require it before they approve the WLS. The Healthyroads program is 6 months. I called Pacificare and asked them what else do I need to be doing since I don't want to do the program for 6 months and then have them turn around and tell me I should of doing something else. Pacificare says that it also depends on your employer and what the plan excludes, requires, etc. Apparently, mine just requires I do this 6 month healthyroads program. I have been to my PCP just twice so far. I started the program in October. I talk with my coach and she goes over nutrician, exercise, blah blah blah blah.  I have to do this for 6 months and THEN i get the referral for the surgeon. I tried already to get the referral to the surg. I thought since at least if I was enrolled in the program they would approve the consultation to the surg. so i could get the ball rolling. WRONG- they denied it and the reason, was because I hadn't completed the Healthyroads program. So, here I am on the program. 6 months isn't that long although it seems like it's taking forever. Keep me posted. I would call Pacificare and have them tell you exactly what they require since my plan may be different. I do know that as of July 2006 i was told that they were requiring all patients to go through this 6 month diet thing (Healthyroads) before they approved anything. keep me posted. I have been on the program since October. Take care. Jaime

Thank you Jamie, that info really helps...good luck!

I am so confused.  i also have pacificare HMO and I have been to the consult and been through the testing and actually have a date.  Are they going to deny me because I haven't done the healthy roads thing?  I have never heard of it!

I think it all depends on your employer and what they require. Pacificare HMO told me that my employer is the one that sets the requirements up so I don't know. If you already have a surg. date then great. I wouldn't worry about it. I was told that Pacificare wasn't covering anyone until they did the 6 month diet with HealthyRoads. I may be mistaken. That is good for you!!! Keep me posted I am curious now.

Yes they require it.  I called Pacificare and my surgeons office.  So I am waiting for a call from Healthy roads.  I need to ask more questions.. but from what I understand it is all over the phone???  whatever!  I would rather actually SEE someone.  but hey what ever thay want to do.  I am willing.  You can read my recent post "attention all pcare members" on the main board for more info.   I am glad I found out now instead of right before surgery!

hi all:) I have PacifiCare HMO and when first time my pcp sent a request for surgery they denied it because i have to complete 6 month Healthy Roads program. I was very upset and i found out about it, but i had to join it, especially becasue insurance pays for it. I gotta say that by my 3rd month i was so fed up with it i wanted to give up but thanks to the support of my family i went ahead with it. ( i think thats one of the reasons why they put you on this program to have you quit, or pay for surgery out of pocket  because people dont want to wait another 6 months)   so now, i am on my last month of the program:) YEAAAAAAAAAh! 3 more appointments on the phone  and  once i will get a completion letter from them my surgeon's office will go ahead and send another request to the insurance.  my couch says that she doesnt see why  i would not be aproved after completing this program, especially because my surgeon did not require me to loose any weight prior to surgery, although everybody recommend it so the surery will go smoother. So now i am just praying that they will approve my surgery with 100% so i wouldnt have to pay anything.... ( i have seen some people write that they got it covered 100%, how nice that would be!) however i received a letter from my insurance that i will have to pay $50 on the day of the surgery, so not sure what else i will need to pay yet.  anyways, i am very excited and nervous at the same time, everyone tells me that it should be ok, since the only reason for denial was that i didnt have the healthy roads. I will keep you guys posted on it:) p.s. talking on the phone with the couch every week is kinda annoying, but hey you gotta do what you gotta do right:)