Update on TNCare (long sorry)

Well I called tenncare today. First I called the number on the back of my card. They told me the number for omnicare and said that if they are no help to call them back and file a medical appeal. So I called omni and talked to a "lovely" (insert sarcasm here) woman named bridgett. She was absolutely no help. I documented everything that she said and the time I called. Basically, that she would send me a provider directory in the mail (refused to give me a list over the phone). I asked her what steps I needed to take in order to get the process going. The generic "referral from PCP" was given. I told her that my referral had been denied. She then proceeded to inform me that there was absolutely nothing i could do. Tenncare does not pay for bariatric surgery and it was not an emergency so basically there is nothing I could do. I asked her for a caseworker and the reply I got was your case worker is the person you go see to get your insurance renewed. I "thanked her for her help" (insert sarcasm again) and hung up on her. So then I called the appeal number and talked to a really nice lady who was very helpful. (she actually was lol) She asked me why i was filing an appeal and I told her the story and the conversation I had with the woman at omni. She asked me all sorts of questions as to why I wanted the surgery and I told her that 1. I have dieted all my life. It doesn't work. 2. I am 25 years old and 252 lbs..i feel sick all the time. 3. I have joint pain, back pain, and shortness of breath upon exertion. I told her that I have no comorbidities that I know of and want this surgery to avoid getting really sick in the future (diabetes and all of that). She said she understood. I told her that I do not have to see that doctor in particular, and that if they would prefer me to see someone in network that I would be more than happy too. I told her that I would be more than happy to comply with any of the requirements that was needed in order to get approved. When I told her that omnicare said that they would not pay for surgery I heard her snicker and said I can't comment on that because my calls are monitered but she told me specifically not to worry about that part. She then said that well lets just go ahead and get this appeal in for you.. She said it would take under ninety days to get an answer since it was not an emergency procedure (I beg to differ but whatever). I told her that would be fine and asked her if it was denied would I have to start the process all over again. She said yes and that I would have to give some more reasons as to why I needed this surgery. I told her don't worry that won't be a problem. So now the waiting game begins. So did I handle this okay?? What do you all think?? I really do take everyone's advice to heart and appreciate all the support that you all have given me. For me to just be on this board for two weeks..I feel like part of yall's family. Thank you all so much for your advice and encouragement and thanks for reading my novel. Jess

Jessica, So sorry to hear that you got a bad one the first call. Also glad to know the 2nd was better. It seems like you are started in the right direction. I will personally keep my finger's crossed for you. I hope you get a quick approval. Best of luck to you. If I can help in any way, feel free to E mail me or what ever. I will do my best to help you. Sara.

Hi Jessica, the number on the back of your card, when you call it, ask for a case manager. Give them your name and phone number. Within 24-48 hours someone will contact you. They will help you find a surgeon in your network. While you are waiting the 90 days more or less, get on a Dr. supervised diet program and monthly weigh ins. You will need that. Have your PCP do lab work on you and make sure it includes a glucose test to see how your sugar is. This is a fasting lab. What about joint pain? Do you have any, and have you had to see an othropedic regarding the joint pain? Your primary care Dr. can set up these appointments for you, see a lung Dr. regarding not being able to breath when active. Get letters from all these Dr.'s as either medically necessary or as a referrals. The more you can do while you wait the better chances you have of getting approved. TnCare has been known to pay for the surgery, but they have regulations that you have to meet before they will approve. Always here, Kathy

Thanks ladies. Kathy thank you for all that information..I'm definately gonna write that down and start getting some things out of the way. Definately couldn't hurt. Thinking about getting a sleep apnea test done too..while I'm waiting. I called the number on the back of the card and they seemed kind of confused..i tried to explain it and they said that my caseworker is the lady that i go see every six months to get my insurance renewed, cause I see the same lady each time. And whenever I get a letter in the mail it says your caseworker is so-and-so. I have her number so I'm gonna call her tomorrow and see if she is the person they are talking about and maybe she could help me there..either way she would get me one. Because the people on the phone we're kind of connfused..and I asked them plainly that I wanted a caseworker to help me with this. But thank you both so much for the information. If they do find something wrong with my blood work,sleep apnea, lungs, or whatever the case may be, then that is all the more evidence that I can have that I need the surgery. Thanks again. You all have been a tremendous help. Take care!! Jess

Actually see if you have your provider manual. In it there should be a number that leads specifically to the insurance's Case Management Division. If you cant find one there call TNCare back and see if they possibly have the number specifically to Omni's case management division. Im pretty sure that all insurances have this. Most ppl never need a case manager to get medical assistance. However I did when I was going through the bariatric loop. The case manager that you see every 6 months or so is with human services not the insurance company and they would not be able to do anything for you in regards to getting this surgery approved or with getting you an insurance casemanager. Hope this helps and *huggles*