Tricare Prime Remote...
Currently, I have one more item on my list of to-do's before I submit my package for approval through Tricare. I've been told that Tricare requires a 6 mo. supervised diet. I've called Tricare and documented every time I did and who I spoke to-THEY ALL SAY NO 6 MO DIET, I just have to meet the requirements they have posted on HealthNet Federal Services site. I've heard both good and bad things and I have a few questions.
1. Are there any suggestions you have after dealing with them that I should be aware of?
2. My PCM has written in his referral letter that I am a "27 year old female that is 200% over ideal weight for my small-frame bone structure. WHAT IS 200% over and how is that determined?
3. The only co-morbs I have don't really qualify as co-morbs (GERD, Edema, insomnia, foot and wrist pain, and migraines). I've heard that some people get approved without co-morbs, is this true?
Thanks for your input!
Wendy
1. Are there any suggestions you have after dealing with them that I should be aware of?
2. My PCM has written in his referral letter that I am a "27 year old female that is 200% over ideal weight for my small-frame bone structure. WHAT IS 200% over and how is that determined?
3. The only co-morbs I have don't really qualify as co-morbs (GERD, Edema, insomnia, foot and wrist pain, and migraines). I've heard that some people get approved without co-morbs, is this true?
Thanks for your input!
Wendy
Wendy,
I am Tricare Prime, but I did not have to do a 6 month diet when I was working on approval. I wonder if this is new? I would ask your doctors office to call Tricare and make sure that this is needed. Sometimes surgeons will do this as part of routine proceedure for all patients.
Regarding the 200% and how they figure it out.....Tricare uses the metropolitain weight tables (google). I am 5'4" and at the time of surgery I weighed 252 lbs. By the table the default is medium bone structure and for my height the minimum weight was 124 lbs, I multiplied by 2 and the 200% mark is 248 lbs. If you are at the 200% mark, you will not need the co-morbs.
Good Luck
I am Tricare Prime, but I did not have to do a 6 month diet when I was working on approval. I wonder if this is new? I would ask your doctors office to call Tricare and make sure that this is needed. Sometimes surgeons will do this as part of routine proceedure for all patients.
Regarding the 200% and how they figure it out.....Tricare uses the metropolitain weight tables (google). I am 5'4" and at the time of surgery I weighed 252 lbs. By the table the default is medium bone structure and for my height the minimum weight was 124 lbs, I multiplied by 2 and the 200% mark is 248 lbs. If you are at the 200% mark, you will not need the co-morbs.
Good Luck
Wendi
Wendi,
(Sigh of relief) Thank you VERY much for the input. Actually, it was my NUT who brought it up. "...Ah, I see you have Tricare and they require a 6 mo. supervised diet." I did explain to her that I takled to them already. I also mentioned that Tricare even told me that it may be Cleveland Clinic that requires the diet. She said that Cleveland didn't but that their Insurance Specialist said Tricare claims have been denied in the past for not providing the 6 mo. hist....Ahhhh, not my favorite subject! Any how, thank you so much for making me feel a little re-assured about some of these questions I've had floating around in the wee hours of the morning!
Wendy
(Sigh of relief) Thank you VERY much for the input. Actually, it was my NUT who brought it up. "...Ah, I see you have Tricare and they require a 6 mo. supervised diet." I did explain to her that I takled to them already. I also mentioned that Tricare even told me that it may be Cleveland Clinic that requires the diet. She said that Cleveland didn't but that their Insurance Specialist said Tricare claims have been denied in the past for not providing the 6 mo. hist....Ahhhh, not my favorite subject! Any how, thank you so much for making me feel a little re-assured about some of these questions I've had floating around in the wee hours of the morning!
Wendy
Hi Wendy
Hi I am also tricare-prime and just got approved. did you have a co-pay and if so how much if you don't mind me asking.
thanks
patty
Hi I am also tricare-prime and just got approved. did you have a co-pay and if so how much if you don't mind me asking.
thanks
patty
Hi Patty
I am SO HAPPY for you that you got approved!!! I don't have a co-pay but this is what my plan looks like on HealthNet.com:
Catastrophic Cap (Cat Cap)
The Cat Cap is the maximum out-of-pocket expense in any fiscal year for TRICARE beneficiaries.
Deductible and annual out-of-pocket expenses
In TRICARE Standard and Extra, the deductible is the portion of healthcare expenses the beneficiary pays out of pocket before any coverage applies. In TRICARE Prime, the beneficiary has no deductible unless he/she receives care the Primary Care Manager did not arrange. Then the beneficiary must pay a deductible with the Point-of-Service option.
Point-of-Service (POS) Option
This special type of coverage applies only when a member of TRICARE Prime receives non-emergency care that has not been coordinated by his or her Primary Care Manager. The Point-of-Service option allows a Prime member the freedom of choosing. However, when using this option, the member must also pay cost-shares and deductibles.
However, when I went to the psychology eval for the pre-op screening, they said I had a copay, but I didn't have to pay that because I told them that I have Tricare Prime Remote and that since their doctor was on our approved network, we weren't required to have a co-pay. I think that was just a glitch in the system because I've never had to pay anything out of pocket (except parking!) since we've been away from a base.
Hope this helps a little!
Wendy O.
I am SO HAPPY for you that you got approved!!! I don't have a co-pay but this is what my plan looks like on HealthNet.com:
Catastrophic Cap (Cat Cap)
The Cat Cap is the maximum out-of-pocket expense in any fiscal year for TRICARE beneficiaries.
Deductible and annual out-of-pocket expenses
In TRICARE Standard and Extra, the deductible is the portion of healthcare expenses the beneficiary pays out of pocket before any coverage applies. In TRICARE Prime, the beneficiary has no deductible unless he/she receives care the Primary Care Manager did not arrange. Then the beneficiary must pay a deductible with the Point-of-Service option.
Point-of-Service (POS) Option
This special type of coverage applies only when a member of TRICARE Prime receives non-emergency care that has not been coordinated by his or her Primary Care Manager. The Point-of-Service option allows a Prime member the freedom of choosing. However, when using this option, the member must also pay cost-shares and deductibles.
However, when I went to the psychology eval for the pre-op screening, they said I had a copay, but I didn't have to pay that because I told them that I have Tricare Prime Remote and that since their doctor was on our approved network, we weren't required to have a co-pay. I think that was just a glitch in the system because I've never had to pay anything out of pocket (except parking!) since we've been away from a base.
Hope this helps a little!
Wendy O.
I have Tricare Prime (not remote) and I DID have a supervised diet to do. I had 2 different surgeon practices tell me that and I called myself because I knew I saw on here that it wasn't needed. I was told it was a new policy for 2008 with the approval of the lap band.
but I know that since then I've seen folks on here not have the diet. so I don't know.
Mandy, Mom to Jordan (5), Kaida (3) and Luken (born 12/5/09) Army wife! HW:351 / SW: 328 / CW:149/ Goal weight...what is that?
Mandy,
The only difference I see is that you had the lapband and other people that I've talked to have had the RNY without the diet history. I guess it depends on the region your in also. I just talked to a tricare rep and she was willing to call the insurance specialist at cleveland clinic and advise her that a 6 mo diet hist wasn't required, but that a visit to the NUT was. (sigh) Well, just pray for me I guess! I have an appointment on Dec 7.
Thanks,
Wendy
The only difference I see is that you had the lapband and other people that I've talked to have had the RNY without the diet history. I guess it depends on the region your in also. I just talked to a tricare rep and she was willing to call the insurance specialist at cleveland clinic and advise her that a 6 mo diet hist wasn't required, but that a visit to the NUT was. (sigh) Well, just pray for me I guess! I have an appointment on Dec 7.
Thanks,
Wendy
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