Anyone with Empire BCBS??

I have Empire BlueCross and BlueShield and they approved my surgery no problem. I thought I was one of the lucky ones and I guess I was, in a way. However, now that I have no restriction and my surgeon agrees that it's time for a fill, they refuse to pay! They sent me a letter saying "Insufficient clinical to certify request, therefore denied." To quote the SpongeBob movie...

What the scallop? (WTS)

Thank God I have managed to keep off the 22 pounds that I've lost. But you know it's just a matter of time. I am really frustrated with BCBS. I call and get transferred all over the place, and no one will tell me how to get approved! There is an appeal process but I wonder how successful that will be. Do any of you have any ideas or suggestions for me?

I almost wish they had never approved the surgery. What is the point of having the band placed if I can't get fills? I could have dieted without risking my life on an operating table, thank you very much!

Your surgeon's office needs to send clinical information to the insurance company in order for them to approve the fill.  They are denying the precert because of the information missing was not sent after a period of time - usually several days to weeks. I don't know what would be required, but SOMEONE at your surgeons office should know or be able to find out what is required *and send it to the insurance company* in order for the request to be approved. You are also entitled to this information about EXACTLY why they are denying the request.  You MUST do that in writing.  Otherwise, you have no way to prove anything, not even that you ever contacted them. Good luck, hope this helps. Irene

Thank you Irene! My surgeon's office tells me that they sent all kinds of documentation into the insurance company, but the fill was still denied. I will be diligent though about making sure they are doing all they can to get me approved. Meanwhile I will write a letter as you suggest. I think even as my surgeon is trying to get my case through the appeals process, it would be good to have in writing exactly why they denied it.

Thanks again for your response.

It's possible the case manager handling your file is NOT receiving the clinical information, or it's not what they are looking for.  Your involvement can only help. I am certain this is a miscommunication of some kind.  No insurance company would approve a surgery and then deny all future fills.  Be persistant! Irene

DEAR JUDY,       IRENE IS SO RIGHT.   I WOULD ALSO CALL "CHRIS  RN".      IS SHE YOUR NURSE? I WOULD GET HER INPUT,  AND SEE WHAT SHE CAN FIND OUT ON HER END. SHE MIGHT BE ABLE TO GET YOU MORE INFO SO YOU CAN CALL YOUR INS CO. ASK FOR YOUR CASE MGR.  THAN ASK FOR THEIR BOSS IF YOU ARE NOT GETTING ANYWHERE.    ALSO ASK FOR A COPY OF ALL THINGS SENT BY DR. GOLDSTEINS OFFICE. WHEN YOU CALL DR. GOLDSTEIN'S OFFICE ASK FOR CAROL  "OFFICE MGR". EXT. 21    ...................ASK HER IF SHE CAN LOOK INTO WHAT WAS SENT , AND IT THERE IS ANY OTHER INFO:  THAT THEY CAN GIVE YOUR COMPANY. KEEP US POSTED.       HAVE A GOOD WEEK MY FRIEND. BRIDGE

Thank you! I'm still trying...

Arbmom, Thanks for bringing this to our attention.  I 'm still  in the pre-op  phase, but this is a question  i must ask my insurance co.    I can't imagine what   additional info  they need  !? They know you had the surgery!! Thanks again, Jan

Oh you have Dr Goldstein too! Do you have Empire BCBS? Someone on the lap band board said she called them and they told her that fills are covered and there is no out of pocket. I am really wondering if maybe there was some terrible mistake that no one will ever be able to explain. I fully expect that one day Joanne will call and tell me my fill was approved and all of this anguish will be just a horrible memory.

...from my typing fingers to God's ears!

FYI, Empire finally approved the fill! I don't know what happened but my doctor's office called me this morning and told me I was approved.
All I can say is, thank you GOD!

Who cares the reason?  The important thing is they DID approve it and you can now get the fill you need!  All the best. Irene