Recent Posts
Topic: So Frustrated with Tricare Prime
So on my blog I posted how I started the process here in Hampton Roads on Dec 3. My PCP submitted a referral to the Tidewater Surgical Specialists Group for an evaluation. I attended the seminar and then saw Dr. Gregory Adams who indicated I was a good candidate for Gastric Bypass surgery. I did the all the pre-reqs in late December (Psych, labs), and attended a support group meeting in early Jan. His surgery scheduler gave me tentative date of 21 Feb, and on the 24th she submitted my paperwork to Tricare Prime (North) for the approval for surgery. Today she contacts me and tells me that I was denied. The reason---------- My PCP put the wrong diagnostic code on the original referral. They put an upper respiratory problem instead of morbid obesity. So now I had to contact my PCP and have them resubmit for a new referral with the correct code and hope that it gets approved so that the surgery scheduler can resubmit the surgery paperwork before my tentative date, else I will have to wait until march or april. The kicker, is that Tricare said that there is a good chance that Portsmouth Naval will override the referral and assign me to the Naval hospital for it. And they have a 3 year wait for the surgery. And to make matters worse, all the stuff tricare paid for under the old wrong referral may be taken back, and I would be responsible for everything so far. So to say the least I am is peaved big time.
Topic: Tricare Claim question
6cc's in a 10cc band
So, I have Tricare Prime. Therefore, a long as it's requested by either my surgeon or my PCM and I get a referral for it, I'm covered. I just got a claim in the mail for $630.00 bucks. Saying that's my patient responsibility for the anesthesia from my EGD. They covered everything but that. Now, I know other people who had some sort of WLS with Tricare through the same surgeon and they all said they didn't have to pay a penny. This is the second thing I've gotten with "Patient responsibility" on it saying it's non-covered by Tricare. (the first being my Psych Eval but I appealed that) Now, both times it's just said "Obesity is non-covered." So, is it the doctor just not putting in the right code for the claim or what? Who should I call. Cause I'm certainly not paying $630 bucks when others that have gotten the same exact surgery have paid $0. Should I just appeal this one as well?
~Karen~
6cc's in a 10cc band
Topic: Federal Blue Cross/Blue Shield Basic Option
I had my 1st app. with my bariatric surgeon last week. My BMI was 37, and I have 2 comorbidities. The new 2011 BC/BS requirements state I must have had a BMI of at least 35 for at least 2 years. My BMI has been between 30 and 33 for most of the previous 2 years. Does anyone know how I might still obtain approval? Thank you!
Topic: RE: can anyone approved by Aetna answer a couple questions for me?1
hi there Nan.....i too will be dealing with Aetna....i have to do a 6 month PCP visit count.....anything you can send me i would so appreciate!
Topic: RE: Fed BCBS do they use your first weight??? What about supervised wt loss?
Thank you! I spoke with my surgeon's office and they were going to talk with Dr. and for me not to start liver reduction diet yet.
Thank you for your help!
Lynn
Thank you for your help!
Lynn
Topic: RE: No Idea Where to Start????
1. Where do I start? (How do I go about getting this process started?) BCBS AL requires the patient to have a 6 month supervised diet and must run consecutive months with no lapse in months so I would first start seeing your personal physician and start the 6 month supervised diet is the first place to start
2. BMI has fallen (in the past) under 35 but not for long, is this a problem? The process will start with your begining weight at the time you start 6 month supervised diet, yes if you fall below BMI 35 it may be a problem. However you mentions high blood pressure and that could be considered as a co-morbidity
3. I would like to have another child, not in the immediate future (maybe another 2 to 3 years). Would this be a problem? After weight loss surgery that a individual can become pregnant a couple years down the road should not hinder. I
If you have further questions do not hesitate to contact me via PM
2. BMI has fallen (in the past) under 35 but not for long, is this a problem? The process will start with your begining weight at the time you start 6 month supervised diet, yes if you fall below BMI 35 it may be a problem. However you mentions high blood pressure and that could be considered as a co-morbidity
3. I would like to have another child, not in the immediate future (maybe another 2 to 3 years). Would this be a problem? After weight loss surgery that a individual can become pregnant a couple years down the road should not hinder. I
If you have further questions do not hesitate to contact me via PM
Topic: RE: BCBS??? I'm confused Please Help
Can you tell me what state the blue cross is out of and I can tell you if it has to be your PCP vs the Bariatric Center. Most BC polices do no allow the Bariatric Center to be where the 6 month supervised diet is documented
Topic: RE: Fed BCBS do they use your first weight??? What about supervised wt loss?
FEP will go by your begining weight as the BMI when you orginally see the surgeon, that is how most surgeons office send in for pre determination and authorization I have also included the FEP 2011 guidelines for WLS
FEP 2011 Definition of Morbid Obesity:
A condition in which an individual has a Body Mass Index (BMI) of 40 or more, or an individual with a BMI of 35 or more with co-morbidities who has failed conservative treatment; eligible members must be age 18 or over.
Benefits for the surgical treatment of morbid obesity, performed on an inpatient or outpatient basis, are subject to the following pre-surgical requirements.
The following requirements apply to gastric restrictive procedures, gastric malabsorptive procedures, and combination restrictive and malabsorptive procedures to treat morbid obesity:
- Diagnosis of morbid obesity for a period of 2 years prior to surgery.
- Participation in a medically supervised weight loss program, including nutritional counseling, for at least 3 months prior to the date of surgery.
- Pre-operative nutritional assessment and nutritional counseling about pre- and post-operative nutrition, eating, and exercise.
- Evidence that attempts at weight loss in the 1 year period prior to surgery have been ineffective.
- Psychological assessment of the member's ability to understand and adhere to the pre- and post-operative program, performed by a psychiatrist, clinical psychologist, psychiatric social worker, or psychiatric nurse.
- Patient has not smoked in the 6 months prior to surgery.
- Patient has not been treated for substance abuse for 1 year prior to surgery.
Topic: RE: BCBS Alabama-- HELP!!!
No, if it isn't causing medical problems it won't be covered and you know, it really shouldn't. That's not what insurance is designed for.
Previously Midwesterngirl
The band got me to goal, the sleeve will keep me there.
See my blog for newbies: http://wasabubblebutt.blogspot.com/
The band got me to goal, the sleeve will keep me there.
See my blog for newbies: http://wasabubblebutt.blogspot.com/
Topic: RE: BCBS Alabama-- HELP!!!
to my understanding because i lost xxx amount of weight and have an apron i could have a panni. to help get my body back to being "normal" and not disfigured. is this not the case? im not really wanting anything "added" just the skin i cant tone removed.
Most Active
Recent Topics
My insurance will not pay for my excess skin that hang down to my knees
Hockeymom87 · 0 replies · 605 views
Hockeymom87 · 0 replies · 605 views
