Question:
Need info ASAP

I got a benefit statement from BCBS today and saw that my consultation with Dr Spiegel was DENIED ...just the consultation they havent even requested servces yet.So where do go from here? Am I supposed to get a letter stating the reason for denial from Blue Cross do I proceed with an appeal? not even sure what info I need to get from the insurance company anyone who can help please respond asap! Thanks    — Lisa F. (posted on February 24, 2003)

February 24, 2003
The EOB you received should show a code to say why the claim was denied and then somewhere else should be an explanation for the code. If you don't find that anywhere, call and ask.
   — garw

February 24, 2003
I also have BCBS, and I also had my consultation visit with my surgeon was denied. BCBS then later approved me for surgery on April 3. I called my surgeon's office and they told me that in a lot of cases the initial consultation is denied, and later picked up after approval. Don't fret about the consulatation being denied just yet. Hang in there.
   — tpalmer

February 24, 2003
I also got the denial, I had (anthem) BCBS I belive that it is standard to deny all claims connected to the surgery until you get approved, you should definitly appeal. They will probably also tell your surgeon that You need 12 mo. Doctor supervised diet, but if you appeal you should be able to get approved and you should be able to get the payment in full for all bills I think I have to pay like a 25$ copay for the hospital, that is it. My date is 4-22. If you call your surgeons office and explain you are appealing they will hold your bill until your surgery is complete. This is the norm. Also there is a really good letter if you go in under the home page on this site and pick the foot for insurance trouble there is a sample letter which is a good tool to send to BCBS to win approval. Good Luck, Leann
   — reallytrusty

February 24, 2003
Like the others said BC/BS won't pay anthing for treatment of obesity or MO until things have been reviewed and approved. In my case I still had an HMO (not BCBS) at the time I wanted my consult and decided to pay for it out of pocket as I knew the HMO would not cover it because they do not cover WLS. It was $110 as no testing was done, just an opportunity to talk to the surgeon and ask questions. I did not want to wait the 4 weeks till January 1st, when my insurance changed. I wanted to take advantage of the month of December to get all my stuff in and get my approval. BCBS indicated they would process the approval, even though my insurance had not kicked in yet. We just needed to indicate surgery would occur after January 1st. It worked because I got my approval on January 3rd. <p>If it is clear that your policy covers treatment for MO and you meet the qualifications then most likely the surgery will be covered. However, the cost out of your pocket will depend totally on the policy you have. My policy has a $500 deductible and 20% co-pay up to another $1500 out of pocket, for a minimum of $2000 out of pocket. Because I have had a number of expenses prior to my surgery I might not have to pay anything or much on my surgery, but I still have to lay out the $2000 at the beginning of the year to cover all the charges that have amassed. But I would have to pay that anyway, WLS or not. I have it taken out pre-tax and put into a medical expense reimbursement account, so it's not nearly as bad and I don't have to have all the money in there to access it. So they will end up paying me the $2000 by the end of March, yet the account won't have all of the money until my December paycheck. A very nice interest free loan in reality! <p>I would not bother to appeal at this time. Get your surgeon moving on submitting your pre-approval for surgery. Once you have that then call them up and tell them you have approval for treatment of MO and therefore this initial consult, which was required in order for the surgeon to submit for approval, should be paid. My guess is it will be paid without any need to file an appeal. Appeals with BCBS can take FOREVER! I think you would get it paid sooner if you try what I have suggested. <p>I'm assuming your EOB has something about this not being a covered service on it. That is the only explanation you will get. Lite a fire under the surgeon and get the show on the road. I had approval in 10 working days, although it was over the holidays so it was more like 5-1/2 working days from when they received it. They were closed for 4 of the days. Call your insurance and ask specifically where pre-approvals should be sent as many times it is not the address on the back of your card and it only delays the approval process. Also ask what they require for review. My policy required a psych eval, letter of medical necessity from the doctor and detailed diet history. Funny thing is that my internist was way behind and never got anything to the surgeon. So my stuff was all submitted without anything from my internist and I got approved. Although I had notes sent from other doctors documenting some of my co-morbs. I consider myself a BCBS expert, at least for my policy, as I have dealt with them for 14 of the last 15 years and have won 2 appeals with them. One took 3 years, but I won. <p>As far as diet history, I do not know exactly what they wanted but they allowed me to submit it, without any proof of physician supervision, and it was acceptable. I had some good diet attempts but most were back in 94/95 and 97, so I was a little afraid they would want something more recent. I did do Xenical for 2 months in 2001/2002 and then tried Welbutrin to curb my appetite with basically no success. They never came back about anything related to diet, so I guess it was satisfactory. Although I had just been diagnosed with moderate to severe sleep apnea which I am sure did not hurt the approval either, even though I way more than qualified, 63.8 BMI. Good Luck!
   — zoedogcbr

February 24, 2003
I have Bc/BS and they do not pay for consultation. On your EOB on the last collum RSN (A) and on the bottom (A) this service is not a covered benefit. They did the same for my consultation for my psych eval and when I ruptured a disc in my lower spine they denied the consultation for the neurologist too but paid for that surgery. So I wouldnt be too concerned. Good luck :0)
   — wizz46

February 24, 2003
I wouldn't get discouraged just yet. I have BCBS of Colorado and my consultation was denied as well. Then after all my paperwork was submitted for the preapproval of my surgery I heard I think 4 days after that I was approved. I then called my insurance company to ask them if I was approved for the surgery, how could I be denied for the consultation? I explained to them that my surgeon wouldn't plan on operating on someone without first determining himself if he/she was a candidate for the surgery. They simply said, "your right, we will resubmit it for you. Sorry about that." Anyway, I hope that helps, and good luck to you! :)
   — Laurel C.

February 25, 2003
Rosemary, I sure hope things are being coded right. Not paying for a consult with a neurologist or neuro surgeon is insane and I have always had any office visits/consults paid by BC/BS. It's only in the case of something that requires prior authorization, like treatment of morbid obesity, do they not pay initially. The reason the psych consult wasn't is because it was for your surgery and someone coded it that way. But once you had your approval you should have requested reevaluation of those claims for payment. I sure would not take no if they ended up approving the surgery. It's just their process of messing with people's minds.
   — zoedogcbr