2 Questions!

I have BCBS and I recently filled out the patient packet. I asked when I sent them in if she wanted me to have my dr's records sent in to the office. She wrote back today and said that they were going to send in a letter of medical necessity to BCBS of Illinois right away. She also suggested that I ask what my benefit level is for the treatment of morbid obesity. She said that as with most BCBS, they have a reduced benefit for that coverage.

I have two questions:

1. Shouldn't she have all of my records before she sends in a letter of medical necessity? I've heard you can only have two appeals and I definitely don't want to waste one of them!!!

2. Does anyone know about the benefit level for BCBS of Illinois? My husband's co. changed ins co. last month and the paper I received states that they cover 80% after $500 deductible for specialty care, 80% covered after ded. on hospital copay and 80% after ded. on Physician/surgeon services. My annual out-of-pocket max. is $2,000. This information was on a benefits comparison guide that the company sent to us to help us determine which plan we wanted. They have not sent us a book stating the plan's dos and don'ts, will pays and won't pays. I don't know much about insurance, but it seems to me that they can't charge me more than $2,000 for the entire procedure, visits, etc. Am i right????

Thanks for the advice! Karen

It depend on the specific language in your policy.  I have BCBS of Illinois and I have a 250 deductible with a 90/10 coinsurance with an out of pocket max of 1500.  In my policy it states that figure includes the deductible, so the max I should have to spend is 1500.  If I were you, I would check your local forum and message boards to see if you have a surgeon in the area that has an insurance lady that handles all of your stuff specifically.  The local message boards by state are very helpful in getting an idea of what surgeon you want to use.  BCBS typically will give you an easier time on approval too if you choose a Blue Center of Excellence for your surgery.  If you go to your state forum, you can get info on all the surgeons in your state, they even have a stats page that tells how many surgeries of what type your surgeon has done.  It also gives a patient reviews section as well.  That is what helped me decide on my surgeon. As for what they needed from me to submit, my surgeons office made me get all of the pre-op tests done and a psych consult as well as a dietician visit and 2 support group meetings before they would submit my ppw with my med records to insurance.  The only question I had for my insurance lady is will I have to pay for all of these tests out of pocket if I get denied.  My policy doesn't cover weight treatment programs or anything for the treatment of obesity EXCEPT bariatric surgery.  She said I shouldn't have to, I just hope she's right.

ther out of pocket max is generalized for your policy but that doesnt mean that there cant be other out of pocket costs written into your policy, ex. durable med equipment prescriptions, phys herpay ect ... you need to call you insurance company and ask what the coverage is for the surgical treatment of morbid obesity well you can say gastric bypass or lap band but those are the terms they are going to use and if it is an exclusion even thought they wont tell you this... you can apeal it a thousand times it wont be covered. if you still havent made a final decision on the insurance package that you chose i would ask someone in the hr department if you could have there group number and then just call customer service give them that number and they can answer any question about the policy. hope that helped a little good luck