Question:
If both insurances cover WLS but I don't qualify under primary?

I have both Aetna and Medical Mutual (Ohio Med). Aetna is my primary, Ohio Med is secondary. I will not qualify under Aetna's new requirements as I have not met the 6 month diet/nutritionist/exercise requirements. Ohio Med has much more relaxed requirements and I won't have any problems qualifying with them. My question is this...Since Aetna will cover the surgery but will deny me due to not meeting their requirements, can the secondary approve me once the Aetna denial is received? Or, since Aetna will eventually cover the surgery once I meet their requirements, will I have to wait and be approved by them also? Thanks a bunch.    — Carolyn M. (posted on March 5, 2003)

March 5, 2003
Your secondary will cover you. They cant 'not cover' you based on Atena' decision. A secondary just means they will 'pay second' They just deduct what ATena pays. If atena pays nothing - they will 'compute' their benefits and pay what they would pay if they were Primary. They DO NOT coordinate 'benefits' as to well if the other doesnt pay we dont attitude. So, if atena denies you and you know your 'covered' under your secondary. They you will only have 'out of pocket' what your second doesnt pay. If you cant afford that 0 then you could wait for the max coverage.. The ONLY thing is ALL your bills will have to go thru ATena and get 'denied' before submitting them for payment with your secondary carrier.
   — star .

March 5, 2003
I believe what the first poster answered is correct although I would go through seeking approval from both surgeries at the same time. I do not believe you need to have a denial from Aetna. It's just like if you have 2 HMO's that allow access to different groups of doctor's. Your primary HMO doesn't cover the doctor you want to see so you use the secondary HMO to go to that doctor. This is totally legit, whether either one likes it or not. <p>I'd still try for Aetna because if they come around you will stand a pretty good chance of having everything covered by the two. Even if Aetna deny's I would still send every bill through them first and see if after the fact they will cover parts of any of it and then send to secondary. One never knows. Good Luck!
   — zoedogcbr

March 5, 2003
I think you have a stickier issue. I am being paranoid but it would seem that if your primary denies then secondary may follow. But since it is just a matter of time that may not be the case. Good luck with two HMO's and congratulations on finding doctors and surgeons and hospitals that are in both of them.
   — snicklefritz