United Healthcare Letter- What Does It Mean? (Long Post)

Hi, Sorry for the crosspost. I posted a similar message over on the Lap Band board before I found this board. I received the following letter today from the UHC Case Coordinator. "XYZ" will stand for my job: "We have completed our review of your request for coverage of morbid obesity surgery under the "XYZ" benefit plan. Based on the information reviewed, we are pleased to inform you that coverage is available. All covered charges are subject to screening for allowable charges. The final allowable charge will be determined when the bill is submitted and will be based on the actual service(s) provided. Please note, this letter does not guarantee payment. Benefit payment is based on the provisions of the "XYZ" benefit plan and is subject to the guidelines, plan design, and policies effective at the time of service." Then another paragraph about me being a valued customer of UHC. I called the billing coordinator at the hospital, and she wanted to wait until she receives a copy of the letter herself. What it looks to me like they're saying is that UHC does cover it if my job bought the correct policy from them. So do you guys just think this is a form letter they would usually send out to anyone? Or are they trying to prepare me for the fact that my employers are going to put up a road block? My doctor's letter of medical necessity was already sent to UHC in the beginning. Does the necessity letter have any influence on the employer's policy or was that just to get the insurance company to pay attention? Because it sounds like even though everyone knows the procedure is medically necessary for me, UHC is bouncing the ball back to my employer who can now say that they won't cover it if it's an exclusion in the policy they bought, whether it's medically necessary or not. Is there hope if there is an exclusion for bariatric surgery? Does the letter of medical necessity help on the level of the employer in terms of persuasion, or is it just for the insurance company? To further cloud the issues, my surgeon does not participate with UHC, but the hospital does. How long are all the appeal steps? My surgery is already scheduled for 9/15/05, since the hospital would not start the insurance request until a surgery date was set. Has UHC been known to reimburse after the fact? I'm going to keep calling the hospital billing coordinator, but any help or thoughts anyone can add in the meantime would be much appreciated. Thanks in advance.

This letter sounds like you are APPROVED! My letter says basically the same thing, especially about it be a covered benefit, and mine was approved. It should have an approval code at the top and your surgeons office will need that to proceed. If I were you, and for clarity, I would call the insurance company and ask one of the CSR's to confirm your approval for you.

I agree, it sounds like an approval to me. Congratulations! l think the other wording is just to cover them, especially if you wait and your employer's plan changes. I would be a little concerned about your doctor not being in their network, though. You need to really check that out, so you don't get a big surprise if they don't cover his charges. Good luck to you.