Horizon Direct Access BCBS NJ

I cannot believe how difficult it has been to find out what I need in order to qualify for bariatric surgery through Horizon Direct Access BCBS NJ! The first thing I did when considering surgery was called my insurance company and asked what the pre-requisites were (i.e., supervised diet, weight history showing obesity, etc.). They told me as long as I was pre-certified, my insurance would cover everything 100% in-network.

Well, that's great, but what do I need to pre-certify? He couldn't tell me. He said my doc's office had to call the pre-certification line and gave me the number. Oooookay...so I called my doc's office, and they said the surgeon's office would call for that. Well, I don't want to make an appointment with a surgeon until I know what I need in order to be covered!

So, in my frustration, I just called the pre-certification line myself! They said they couldn't tell me anything, that it had to be a nedical professional calling. Umm, hello, is this or is this not the insurance I PAY for every paycheck? Why can't I have information on MY policy?!

Anyway, I called my doc's office about it AGAIN, and they should call that number and get back to me within 24-72 hours.

I did do some searching online, and I found a PDF of a form that looks like it is to be submited by the doctor for approval. It said it requires weight for past 5 years, nutritional evaluation, psych eval and clearance, 6 months supervised weight loss program, and enrollment in a support group. Fine-al pretty standard stuff. But the form has no date on it, so I have no idea how current it is (or isn't!).

It really shouldn't be this difficult to just get information...I'm not trying to hop on an op table tomorow, I am just gathering information!

Oh, and to top it all off, I'm not even sure if they will cover the procedure I want (DS, not RNY or LB). No one could tell me that, either!

I have BCBSNJ and have talked to insurance several times to clarify the requirements.  
I recently started my 6 month diet and don't see the surgeon until next month.  I'm working on collecting the necessary components:  weight history, old lab reports, letters of recommendation, list of diets and exercise attempts, etc...  I want to be ready and plan to submit everything to insurance next month.  I've heard many people say they got denied for DS because insurance says it's experimental but I don't know this from first hand experience. 

This is the list the insurance rep dictated to me.   I hope it helps. 

BMI 40+        
5 years of weight history            
Pre-op evaluation letter from surgeon                        
6 month monitored diet  (must check in with pcp for 6 consecutive months) with documented weight checks, blood work, etc...                
List of diets/exercise plans you've tried
2 Original photos of yourself showing body mass         
Two letters of recommendation from Dr.'s (Pcp and other)         
Surgeon letter                    
List of health conditions (co-morbidity)
Description of surgery, diagnosis and procedure codes to be used
How the surgery will affect your lifestyle and how the weight affects you now


 

Wow...thank you for that! That's more than what I had found online that they required, but I'd rather be prepared for too much than not enough! I've already started gathering past medical records (had to call some docs from back in the day since I was in college 5 years ago, so lots of moving around).

I know there are even different requirements among BCBSNJ plans, so I'm still waiting for my doc's office to get back to me with what my requirements are (Horizon Direct Access PPO). I don't think I've technically started my 6 months supervised diet yet since my last appointment was a follow-up for my diabetes where, of course, we talked about diet and exercise and I was weighed, but I don't know for sure if she included that in her records.

I'm not sure if my BCBS PPO is called direct access.   My requirements seem like a lot so I can't imagine having more than that long list.  Good luck! 

Start your 6 month diet now, just in case.  I'm using  the daily plate.com to track my eating and weight.  I plan to print them for my records and turn them in.

I have an appointment August 11 with my doc as follow up for my diabetes, so if need be, I will start my 6 months then. Meanwhile, if they ever actually CONFIRM that I need those 6 months, I will call her and get a recommendation for a nutritionist and go there asap.

If you do have to do the 6 month diet, make sure you get clarification from insurance as to what dr. you have to see for monitoring.  I've read a lot of people used a nutritionist only to find out it doesn't count.  Then they have to start over.  It seems like most ins companies want the diet to be monitored by the pcp and they want only weight loss codes on the form the pcp submits to insurance each month.  I've heard stories of a month not counting because the dr. coded the form for something other than weight loss. 

Hey Jill,

I do have Horizon Blue Cross of NJ/Direct Access and had DS surgery March 2007.  The requirements listed in Pooh's reply are accurate.  Email me back if you have any questions.

Phillyrose