Question:
Anybody out there have blue cross/blue shield (federal plan)?
I talked with them and they say they don't preapprove this surgery. But they will pay for it if it is medically necessary. I think I am ok with the necessary stuff. So when or how do you prove that it is medically necessary. Do you send the paperwork before surgery or do they go by the claims they receive? — Kim N. (posted on December 14, 2002)
December 14, 2002
hi I have BCBS Fed and they paid very well I had to send them nothing the
Dr.s office did all mine for meand the Dr. lets them know about the
nessecity of it. I had to send them nothing
— Billie G.
December 14, 2002
I have BC/BS Federal and they told me the same thing they told you.
However, my doctors office sent the paperwork to BS/BS and approximately 10
days later I was approved. No problems!
— Karen H.
December 14, 2002
I am pre-op still but have spoken to my insurance company and others that
have Fed Blud Cross like I do, they do not approve before surgery, BUT I
havent come across anyone that hasnt had their's paid. As long as you meet
the requirements they set, being MO, then there should be no problems. I
called because I was concerned if they would pay for all the tests the
surgeon requires. I was told as long as it is part of the program the
surgeon has set, they are covered. There is a $250 detductible I will have
to pay, $15 co-pays for office visits, but other then that, looks like I'm
all set. Just keeping my fingers crossed though! lol
— TheresaC
December 14, 2002
Hi, Happy Holidays! I work for an insurance company. Some plans don't
require prior authorizations which is fine. If you were told it was a
covered benefit as long as medically necessary there should be no
problem...:) After your procedure is completed and the surgeon's office
bills for the surgery, all they will do is submit office notes, lab work
previously done, a copy of your operative report and a letter of medical
necessity for your insurance company's nurse/doctor review board to read.
Once read they just basically look to see if you fall within your policy's
guidelines. (example ..100 lbs overweight ... obesity related health
conditions ... or whatever is stated in your
benefits)<p><p>Really the only difference in having a
preauthorization and doing it after the procedure is when your
doctor/surgeon sends in the medical notes/records to be reviewed. Hope
this helps ease your mind. Bye Bye Mary
— Merry I.
December 14, 2002
Hello, I also have BC/BS Federal. My plan required that the doctor send in
a letter of medical necessity prior to surgery. Also, I found out that if
you don't have a lot of your past diet documentation, that if your primary
care physician or gynocologist has "counseled" you in weight
loss, a letter from them will help with getting approved. My surgeon
submitted his letter of medical necessity along with my letters from my
doctor and I was approved within 2 days. My doctor also had me write a
very detailed letter as to why I wanted the surgery, how it would help me,
what I expected from the surgery and how my life would change after surgery
to assure that I adhere to the guidelines from my surgeon to maintain a
healthy life after surgery.
— Sissy I.
December 15, 2002
I also had/currently have BCBS Federal and was told by the insurance
company that they would not approve it. My doctor's office then talk to
them and they said that I would have to pay for it and then they would
decide whether or not after the surgery. I can't afford that so I am
changing insurance companies.
— C. Zibrowski
December 15, 2002
Kim, I have found that the surgeons office staff is the best advice on
whether the insurance will approve or not, as they have lots of experience
with the different insurance companies and whether they approve or not. I
have BCBS/Fed and was told by my surgeons office that that is one of the
easiest to work with. They scheduled my surgery and sent in the paperwork.
2 weeks AFTER the surgery, I got my letter of approval from the insurance
co!
— Cindy R.
December 15, 2002
Most surgeons are used to dealing w/ins cos and can reassure you, as long
as you are MO. You may, however, run into a few surgeons who are stubborn
and will want you to pay up front and wait. My advice is to not go to
these surgeons, because there should be another one in your city who is
"nicer". With BCBS Federal, you should have a wide choice.
— cddgo
December 15, 2002
I also have BC/BS Federal, and had absolutely no problems getting surgery
covered. My surgeon tried to get pre-approval and they sent him a letter
saying they do not do preapproval. If you qualify for the surgery (100 lbs.
overweight, 40 + BMI, and/or comorbids) you should have no problems. I went
in with a BMI over 50 so I figured there was no way they could say it
wasn't necessary. I have never talked to anyone who qualified and had this
insurance not get covered. They even covered my 10 day hospital stay, 5 of
which were in ICU, with my $100 deductible I would have had to pay anyway.
As far as the surgery itself, they paid 90%. I ended up paying a total of
$800 total with my part of everything. This included 10% of surgeons fees,
anesthetist, etc., $100 hosptial deductible, plus the initial consult was
not covered which was $140.
— sheltie
December 16, 2002
I have BC/BS Federal. I was amazed at the quickness of their response. My
surgeon submitted my paperwork and WHAM, within HOURS I was approved, and
the surgery date scheduled! By the way, my surgery is for tomorrow the 17th
of December! i'm soon to be a LOOSER! Dont Sweat it.
— Raelynn W.
December 16, 2002
Hi. I have BCBS Federal, PPO Standard Option (formerly High Option) plan in
Georgia, and even though it is one of the *better*, but expensive PPO plans
in Georgia, I'm not at all pleased with the amount they paid on my
$59,000.00 hospital bill. I'm currently making plans to do something about
it, but overall they're okay. I think it was a matter of someone not
submitting the paperwork properly. My surgery was definitely medically
necessary and because of it I am reaping GREAT benefits~physically~. You
(preferably your PCP/surgeon) should actually be prepared to prove that it
is medically necessary BEFORE your surgery. In my case, my PCP sent a
letter of medical necessity to the surgeon (it was sort of like a referral)
and the surgeon took it from there in submitting the claim to BCBS AFTER my
surgery was performed. I'd like to speak with claims processing in person,
face-to-face. Check out my profile to see what I mean...
— yourdivaness
December 16, 2002
Hi. I have BCBS Federal, PPO Standard Option (formerly High Option) plan in
Georgia, and even though it is one of the *better*, but expensive PPO plans
in Georgia, I'm not at all pleased with the amount they paid on my
$59,000.00 hospital bill. I'm currently making plans to do something about
it, but overall they're okay. I think it was a matter of someone not
submitting the paperwork properly. My surgery was definitely medically
necessary and because of it I am reaping GREAT benefits~physically~. You
(preferably your PCP/surgeon) should actually be prepared to prove that it
is medically necessary BEFORE your surgery. In my case, my PCP sent a
letter of medical necessity to the surgeon (it was sort of like a referral)
and the surgeon took it from there in submitting the claim to BCBS AFTER my
surgery was performed. I'd like to speak with claims processing in person,
face-to-face. Check out my profile to see what I mean...
— yourdivaness
Click Here to Return