Question:
Clinical Review

My friends paperwork has been submitted to the insurance company for approval. She called the insurance company today and they said her file is in clincial review. What does clinical review? What is the process the insurance company takes to review file? Do they call and confirm weights or what is the process?    — tayee24 (posted on October 21, 2008)

October 21, 2008
Clinical review means that your paperwork is in the hands of the people at the insurance company that review and determine if you meet their criteria for approval. Could be RN who may or may not escalate to a doctor. The time it takes is vastly different from one insurance company to another. Could be a few days to a few weeks depending on how busy they are. If they have any questions, they will either call you or your surgeon's office. Dawn Vickers, RN, BLC, CLC
   — DawnVic

October 21, 2008
It means that a nurse or a doctor are reviewing the information that has been submitted by your physician for the authorization process. They want to make sure that your friend meets the insurance guidelines in order to authorize the procedure. This typically should only take a couple of weeks but depending on the insurance it could take longer. You can contact the insurance and they can give you a time frame. Hope this helps. Good Luck!
   — CLAUDIA J.

October 21, 2008
I have Aetna PPO Open Choice my paperwork was sent over on 10/1. I received a general letter from Aetna just letting me know they received the paperwork. 10/10 Ireceived a call from the docotor office letting me know i was approved surgery 12/5.
   — sawwas

October 21, 2008
Yes, the insurance carrier looks into all of the basic requirements that your friend must meet in order to become a valid candidate and this is souly on the information that she has had all of the various medical teams results that meet their requirements. I have BCBS and received a letter from them that I was approved about 3 weeks after my submission that I was approved. Some are not approved the first time and can appeal their decision and get the extra medical information that is required, then resubmit what they need and voila are approved. I had one friend like that. Nothing to fret, it's just time consuming and it is a major surgery and change of life and the Dr.'s want to make sure you will be safe and follow through with all of the expectations that go along with this procedure. A point to remember before going through all of this is to contact your ins. carrier and ask what they require and take matters into your own hands (complete what is needed to be approved.) plus look up all of the information on the various websites on this matter (pro's-con's) make sure this is the right move for you, and make sure you have all of the documents they request the first time. I studied the internet, read many articles, spoke w/real people who had already had this procedure and asked Many questions, before I had my information sent. I wish your friend the Best.
   — premenewme