Trying to get a prior Auth?

I work for a large insurance carrier and am familiar with the PA procedure. My first suggestion is to have all your paperwork submitted at the same time. You won't get approved if there are tests or documents missing, or if there's not enuff info to determine a medical need for the sx. Your surgeon's office will tell you what info to get together. Most of the time, an insurance company won't tell you what pieces of info they're looking for. Ultimately, every insurance company is looking to see if your surgery is medically necessary. In general, you will need a letter of recommendation from your pcp, medical records going back anywhere from 2-5 yrs, and a report from your surgeon's office indicating that they feel you are a candidate. I know some companies require proof of non-surgical weight loss attempts (Jenny Craig, Weigh****chers) and/ or proof of medically supervised diets, pills, etc. Some insurance companies have a minium BMI of 40, or 35-40 w/ co-mobidities ( arthritis, sleep apnea, compromised skin integrity, etc.) Others require the candidate to be a minimum of 100 lbs over their ideal body weight. Also, you will have to have a psychological evaluation. I failed my first one, despite the fact that I felt I am a good candidate. They want to make sure you have a support system & that your views about the sx and the changes it will have on your life are realistic. Also, there are psychological changes that they want to make sure you can cope with. As I said, I failed my first eval and it was a crushing blow - I almost gave up, but thankfully I tried again & the second time was the charm. The dr told me at the end of the exam that he was going to recommend me. Believe me, if you don't get a green light from the psych, your insurance company will definately deny your request. In most cases, it will be up to you to gather the medical request, rquest the psych eval be forwarded to the surgeon, and any other 'leg work' that needs to be done. You will need to complete forms that allow drs to release med info to each other. Every office you request info from will require this - it is a Federal law. Unfortunately or maybe fortunately, the people reviewing your request for approval do not know you. They can't see you and there's no personality attached to the request, all they see is the paperwork in front of them. When doing a medical review, the drs and nurses look for specific criteria to be met. There is a set of standards each request must meet in order to be approved. This set of standards varies from one ins company to another, but the stuff I listed above, pretty much applies to all insurance companies. If your medical info doesn't meet the criteria, your request will be denied. I hope this helps. If you have questions, please feel free to e-ml me.- Kel