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Topic: submitt everything but....
It's true that we don't know what we've got until we lose it, but it's also true that we don't know what we've been missing until it arrives.
IM DOING ALL OF MY PRE OPERATIVE TEST NOW AND FINISHING THEM UP, I WILL BE DONE BY DECEMBER 21ST WITH THEM ALL 
....I STILL HAVE TO DO MY 6 MONTH DIET WHICH ISNT UP UNTIL APRIL 5, I WAS WONDERING CAN MY SURGEONS OFFICE SUBMITT MY STUFF AFTER I FINISH MY TEST OR DO I HAVE TO WAIT TIL IM DONE COMPLETELY WITH MY 6 MONTH DIET?
....I STILL HAVE TO DO MY 6 MONTH DIET WHICH ISNT UP UNTIL APRIL 5, I WAS WONDERING CAN MY SURGEONS OFFICE SUBMITT MY STUFF AFTER I FINISH MY TEST OR DO I HAVE TO WAIT TIL IM DONE COMPLETELY WITH MY 6 MONTH DIET? It's true that we don't know what we've got until we lose it, but it's also true that we don't know what we've been missing until it arrives.
Topic: RE: uhc choice plus exclusion overide
Hi All,
I too have the UHC Choice plus plan in Georgia. We do have a law on the books but that does not guaranty coverage. I wrote a letter to the State House of Representatives and Senate Insurance Committee and Health and Human Services committee about the issue with the word "may" in Georgia's law. I copied the State Insurance Commissioner and have been dealing with them for a couple weeks now. Here is what I have learned.
1. There are 2 types of insurance plans and each type is governed by different laws and government agencies.
Self-Insured plans - are plans where the company pays all of the medical expenses and can override any decision. The insurance company on the card for these plans is just the paper pusher or administrator of the plan for the company that you work for who is paying the bill. Self insured plans are not governed by or covered by State or Local laws as they fall under a federal law written in 1974 (I believe) and they are governed by the Department of Labor.
*Most Large companies are self insured.
Fully Insured plans - are plans where the company pays a monthly premium to the insurance company to insure their employees. The Insurance company writes the policy and governs it. The company has no say in what will be approved on appeal. The company has to purchase a separate rider for WLS for the plan that we have as it is a fully insured plan. Fully insured plans are governed by the state insurance commissioner and state and local laws apply to them. Most small companies (200 or fewer employees are fully insured)
Here is the dozy, UHC is claiming with the insurance commissioner that our plan is self insured. My HR representative has told both me and the insurance commissioner that it is a Fully Insured plan. I am waiting to hear back from the insurance commissioners office on how to proceed, but I have written an appeal letter and have it on standby. If UHC continues to state that it is a self insured plan, I am going to ask my HR rep to write a letter stating that the company approves of me having the surgery and include that in my appeal.
We can win this fight! We just have to arm ourselves with all the knowledge we can!
I am still waiting to see what comes from all my state representatives about my request to amend the word may to SHALL!
I too have the UHC Choice plus plan in Georgia. We do have a law on the books but that does not guaranty coverage. I wrote a letter to the State House of Representatives and Senate Insurance Committee and Health and Human Services committee about the issue with the word "may" in Georgia's law. I copied the State Insurance Commissioner and have been dealing with them for a couple weeks now. Here is what I have learned.
1. There are 2 types of insurance plans and each type is governed by different laws and government agencies.
Self-Insured plans - are plans where the company pays all of the medical expenses and can override any decision. The insurance company on the card for these plans is just the paper pusher or administrator of the plan for the company that you work for who is paying the bill. Self insured plans are not governed by or covered by State or Local laws as they fall under a federal law written in 1974 (I believe) and they are governed by the Department of Labor.
*Most Large companies are self insured.
Fully Insured plans - are plans where the company pays a monthly premium to the insurance company to insure their employees. The Insurance company writes the policy and governs it. The company has no say in what will be approved on appeal. The company has to purchase a separate rider for WLS for the plan that we have as it is a fully insured plan. Fully insured plans are governed by the state insurance commissioner and state and local laws apply to them. Most small companies (200 or fewer employees are fully insured)
Here is the dozy, UHC is claiming with the insurance commissioner that our plan is self insured. My HR representative has told both me and the insurance commissioner that it is a Fully Insured plan. I am waiting to hear back from the insurance commissioners office on how to proceed, but I have written an appeal letter and have it on standby. If UHC continues to state that it is a self insured plan, I am going to ask my HR rep to write a letter stating that the company approves of me having the surgery and include that in my appeal.
We can win this fight! We just have to arm ourselves with all the knowledge we can!
I am still waiting to see what comes from all my state representatives about my request to amend the word may to SHALL!
Topic: RE: Update: Approved! (Anthem is giving me hissy fits)
Approved!
DS surgery
44 BMI
No Co-morbids
no 6 month diet or 5 year history
Other than the drawn out wait, it was easy!
Anthem BCBS PPO out of CA
Husband's company is self insured with Anthem managing care
DS surgery
44 BMI
No Co-morbids
no 6 month diet or 5 year history
Other than the drawn out wait, it was easy!
Anthem BCBS PPO out of CA
Husband's company is self insured with Anthem managing care
Pamelalalala
Switched on Feb 9, 2011!
Switched on Feb 9, 2011!
Topic: RE: Medicaid and WLS
Aisha if you are going to be around today message me on here and we can talk since I will be home all day today. Talk to you soon. Kim
Topic: RE: Medicaid and WLS
It's true that we don't know what we've got until we lose it, but it's also true that we don't know what we've been missing until it arrives.
ok cool, I was wondering why my wls center wanted me to do mostly all my pre-op test! maybe they will submitt my information too, how do you find that out? do you think i should ask the insurace company (medicaid) or the wls center?
:) aisha <3
:) aisha <3
It's true that we don't know what we've got until we lose it, but it's also true that we don't know what we've been missing until it arrives.
Topic: RE: Medicaid and WLS
Well it will probably be April unless Mainecare will say they will except Sept and Oct office notes even though I was at my dr for other reasons not just to discuss weightloss even though the office notes talk about my obesity and exercise, all my health issues, ect. If they don't except them then it will be April. Also I called Mainecare (medicaid) again today and they told me that they do not require me to have a 6 month dr. supervised diet program but if the WLS center is requiring me to do it then they said just do it. I did ask them if when I finish up with all of the other appointments and in the mean time keep doing the 6 month supervised diet plan. She said if you are done before April go a head and have them submit and if they come back that they do indeed now require the 6 month then you can just finish up with those visits and then resubmit. Have you seen the WLS Center yet and started some of your appointments?
Topic: RE: Medicaid and WLS
It's true that we don't know what we've got until we lose it, but it's also true that we don't know what we've been missing until it arrives.
I have to do 6months and my doctor said the exact same things that its about seeing if Your consistent and stay on the plan not even so much if you lose the weight! Do YOU know when Your 6months is up?? Mines is in April!
It's true that we don't know what we've got until we lose it, but it's also true that we don't know what we've been missing until it arrives.
Topic: RE: My 2 sons are approved by Aetna & have a surgery date!!!!!
Hi! I am in Ohio and have Aetna Open Access. I had RNY in 2003 and have had problems with ulcers requiring scopes twice a year since 2006. I'm getting ready to be scoped again on Friday and am going to start looking into a revision to a DS because I am afraid I have ulcers in the part that is closed off where the Dr can't see. I'm worried that Aetna won't cover it -- although my BMI is still 39 -- I started off at 299 lbs and never got below 230 -- now am back at 250 because the only foods that don't hurt are the soft foods that you aren't supposed to eat.
My original surgery wasn't with Aetna -- how was the approval process? Did you have a lot of requirements and did they deny you up front?
Thank you!
Traci
My original surgery wasn't with Aetna -- how was the approval process? Did you have a lot of requirements and did they deny you up front?
Thank you!
Traci
Topic: RE: Update: Approved! (Anthem is giving me hissy fits)
Yes, that is Anthem BCBS. Of course, within Anthem you have PPO and HMO as well as different rules and coverage for different companies/organizations. My husband's company is self insured using Anthem to manage. My husband's company covers everything as long as BMI is met, but others may not.
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