Horizon BCBS NJ

Hi guys

I am trying this again.  I originally tried for the Gastric bypass back in 2008/2009 but was denied due to lack of 6 month diet.  My doctor upto yesterday did not want anything to do with this.

Yesterday I went to my new doctor and she recommended  the Gastric before I could even ask.  She said that she was going to refer me to the hospitlal/program where they perform these procedures to get started getting ready. She asked if I had tried this before and I told her I was denied based on diet.   She seems to think they can get this done and soon.  

My question is it has been a couple of years since I have tried for approval and Horizon was pretty tough at that time.  Has the rules changed since then.  I had a case manager for Horizon tell me a earlier in the year tell me that she thought she could help me get approved but I needed to get well with my legs first.  I tried to call her back about a month later and she is no longer with Horizon. 

Just wondering if anything has changed.

 

Thanks for your help

Bob

 

 

 

I have one more question 

With Horizon BCBS-NJ my deductible has been hit for the year.  If I am approved this year would there be any charges billed or is WLS are you still respomsible for the 20%.  After the first of the year our deductible will go up to 2500.00 Does this surgery apply to the deductible I guess is my question.

Update...

I just heard from the surgeons office today and they are saying that I am covered but I will be responsible for 20% with no deductible... 

Is this 20% of the total cost or does BCBS have a negotiated price that they go off of.
 

I also have Horizon BCBS of NJ, but unfortunately I am too early in the process to be of much help.  I called them this past week to ask what the requirements would be to obtain precertification, but the customer service rep said she didn't have the information and the department that did would only work directly with physicians' offices.  So I'll have to wait and see what happens after my initial consult next week.

Regarding the 20% - are you looking at an out-of-network surgeon?  I was hoping with an in-network surgeon they would cover more than that, but maybe I'm dreaming.  I am being switched from Direct 10 to Direct 15 as of January 1st, so if they make eveyone pay out-of-network costs, I guess I'll be looking at 30% instead of 20%.

This is actually my second trip through the process... 

Two years ago I went through the process and was denied by BCBS-NJ.. The hospital group that I was going through did not help out alot and did not give much info.  It seems like when I was denied they pretty much just dropped me. 

BCBS denied me due to lack of a 6 month diet.   I had a PCP that did not believe in WLS.  Now the new group that I am working with is saying due to my size that they maybe able to get me by without the diet...  This is the biggest problem so far is the different stories that you get.  

This new hospital group is in network and they stated that it would be the 80/20 split in which I would be responsible for the 20% with no Deductible.   Not sure if this applies to the out of pocket max or not. 

Good Luck to you.

In order to know exactly what you need, you need to call your insurance company and either request their bariatric policy book in paper form or direct you on their website where it can be found. The requirements will be listed but doing them to their standards will be diffcult. When you are on your diet, record everything from what your dietician tells you to eat, weight, bmi, recommended exercises, recommended lifestyle changes, changes that you have made and keep a food log. If they provide you with any documents, submit. Make sure you get a letter from your dietician and your pcp recommending the surgery due to a failed 6 month diet. Hope this helps.