United HealthCare Military - Tricare Prime - My story - Gives someone some hope.
I just wanted to let others know of my experience with Tricare Prime and paying for my RNY. When I was researching I read some hopeless comments so I wanted to let others know my story and hopefully that will help them and give them some peace of mind trying to have theirs approved through Tricare. I used a civilian hospital that was a ceter of excellance for bariatric. Our closest MIL Hospital is in Utah or Washington.
I have other health insurance, but we knew from the start it had an exclusion for weight loss surgery. I had to have my lapband removed, I was in the process of having a hysterectomy so my GYN surgeon and my RNY surgeon teamed up and we had my lapband removed while I had the hyst done. Tricare paid the RYN surgeon fee to have my band removed since my Primary insurance would not touch it. They also itemized my bill from the hospital and Tricare paid the fees that my OHI would not due to being specific for the lapband removal. We started working on the Tricare requirements to be approved for Tricare for RNY. At that time they required 6 months of physician supervised weight loss attempt. I took a few months to recover from hyst and then started they 6 months of supervised visits. Neither my primary or Tricare would pay for weight loss appts. but my primary Dr. coded my visits in regards to my high blood pressure and edema of the feet and other issues, both insurances then paid for my appts. In October the RNY surgeon insurance manager submitted the approval to my primary insurance, even though we knew they would deny the approval, we needed it in writing to submit to Tricare for their approval. Once we had that they submitted to Tricare, they denied the approval "due to having other health insurance" they would not approve. We figured this would happen, so the insurance staff followed up with a detailed email and phone call to a specific dept @ Tricare and explained what was going on and what was needed. Within a few days we had written approval from Tricare. I had my surgery and then I received my first EOB from Tricare denying the charges..they needed the charges to be submitted to my primary and denied before they would pay them, even though they already they already had a blanket denial from the primary from requesting the approval.. I had the hospital and surgeon submit to the primary and then resubmit with the denials to Tricare. Yesterday I received my EOB from Tricare they have paid the hospital and surgeon charges and I owe 25.00 as my co-share. I still have 1 bill out that has to go through the primary denial and then resubmit process but it should be paid as well with a 25 co-share. It was a process but not too bad and overall to pay 50.00 total for a 33k surgery I can jump through a few hoops and wait a little.
Send me a message if you have any questions. Hope this helps someone.
Jaq
Tricare did not pay for my lapband surgery in 2006. I had private insurance at the time that covered the surgery. I married my husband in 2010. I had my lapand removed during my hysterectomy.I carry my private insurance as a primary insurance and Tricare Prime as secondary. Since my primary insurance approved my hysterectomy Tricare picked up the "remaining" cost that included my lapband being removed. We had to make sure my GYN surgeon opened me and closed me, the lapband surgeon came in to remove adhesion's so the GYN surgeon could perform my hysterectomy easier. The lapband surgeon removed my band while he was in there. My primary denied the lapband surgeon fee but Tricare covered it as the secondary insurace along with the other fees from the hyst. Kind of a special situation but both surgeons want my band out and for me to have RNY so they worked together to help get it done. My band was ineffective I lost 100 in the beginning but after that it was a struggle with getting the right fill and I just got so frustrated with it. I ended up with GERD and tons of adhesions.
jacqie
Hockeymom87 · 0 replies · 611 views
