Does anyone know how to translate "Insurance Speak"? Kind of long... sorry

OK - for a quick bit of background.  Last fall, my insurance told me/my surgeons office that I had bariatric coverage and met all the criteria for it.  Then, my surgeons office sent in the paperwork for pre-approval (around the 1st of Jan.) and the insurance denied the claim, stating that this was not a covered procedure.  I obviously appealed and I got this response:

.....After reviewing your request, including all medical information received, it has been determined that the service is not eligible for benefits as you requested.  According to your Benefit Plan, this request for service was processed correctly.
The Benefits for this plan are for in-network benefits only.  There are no benefits provided for out of network services under this plan.  Jon Gould MD is not contracted with the network you plan uses.  Therefore, we uphold our prior decesion to deny coverage for this service.

My initial translation is that they are no longer covering my surgeon BUT I do have bariatric civerage.  So.... I need to start over with a new "approved" surgeons office now?   Is this wishful thinking or am I understanding this correctly?  Any thoughts???? HELP!

Thanks,
Nicki

It sounds like the surgeon you went to (Jon Gould) is not in the network.  It could be that last fall he was in the network but now he is not.  I would talk to your insurance company and find out which bariatric surgeons in your area are "in network".  

YUP!  I already looked it up and found the "new" list of Drs.  I just wasn't sure if I was translating things correctly because origionally - they stated the service wasn't covered - which made me think the actual surgery wasn't covered.  Now it seems that they are saying the surgery is covered but the surgeon is not... I think....  Why can't they just write things in regular english? LOL
THANKS!
Nicki

My read is that they are denying you because you requested the service be provided by an OON (out of network) doc.
There is NO reason you should have to guess however.  When I was denied I was told I could call the insurer to have a discussion so that I would understand why they denied the surgery if I had questions.  Get a beverage, a comfortable chair, plan to maybe be put on hold, AND insist politely that you get connected with someone to answer your specific question: "If I use Dr. X who is in network, will I qualify for coverage based on the information in my first request?". 
(I got my denial reversed.  I called the insurance folks about 6 times during that process).
GOOD LUCK!
Anne

Good luck Nicki!  Dr. Gould's office should be able to get you copies of your records to get to your new, covered provider so that hopefully the process will go quickly for you.  Make sure that you tell your new surgeon's office that you have completed most of the process so that you can move quickly!
Good luck - we look forward to seeing that you are approved and moving forward!
Warm Regards,
Kim

Upon preparing my second appeal, I found a letter from our Human Resource Dept. stating that all UW Clinics and Hospital would be covered by UH****il June 30, 2010.  Dr. Gould is a UW surgeon SO, I am assuming that UHC is in the wrong.  I copied it and sent it with my appeal.  Hopefully, they get back to me within the next week or two so that I can proceed with Dr. Gould!   I fear that UHC will drag their feet and not get back to me until May... LOL
Keeping my fingers crossed!
Thanks everyone,
Nicki