Letter for BCBS of TN....Approved or Denied?

[Gotta win 4me 12]

Let me share my story......On October 22, I was called by the Insurance specialist, at the Surgeons office that faxed all my paper work to BCBS of TN....she called to tell me that I had been approved for the surgery...I was all excited! She made an appt. for me to come in to see the surgeon and set my sugery date on the following Wed. October 27. On the same morning before I went to see the surgeon I checked the BCBS website to check the status of my Pre-Auth and it states that it is "Disallowed":scared2: and that was submitted on the 24th of October. I asked the IS if she was sure I was approved because of the online site and she was adament about the nurse over my case saying that I was APPROVED:thumbup:. She even gave me a copy of the reference# and the nurses number where she took notes when she spoke with her....the nurse also wants her to call her back wiith my dates of service. Apparently on the 25th of October a letter was written and sent in the mail to my address in reference to the surgery...it reads as follows::wink2:

"Dear Member,

The Purpose of This Letter

Recently, BlueCross BlueShield of Tennessee recieved a request from your provider asking us to determain whether your health benefit plan would cover the following procedure: Laparoscopic Adjustable Gastric Band Surgery.

Based on the information that your provider submitted, these services are determained to be Medically Necessary. However, it's important to keep in mind that the dertermination that a procedure is Medically Necessary is not a final comfirmation of coverage or benefits. Payment of benefits depends on terms, limits, conditions, and exclusions of your health benefit plan, as well as your eligibility at the time you recieve services.

This decision is valid only if all the medical information we recieved is accurate and complete, and is effective until the end of your current benefit period, not to exceed one year."

I know I could easily know what going on if I call them but I don't want to hear any bad news on purpose. The insurance specialist at the surgeons off is suppose to call BCBS with my dates of service before services are rendered. I apologize for the lengthy message but they could have just used the words APPROVED or DENIED!!! It is covered based on my insurance plan so I don't know what to make of this....I guess ima wait until the IS call me back after reporting my DOS to the Nurse over my case. Insurance lingo.>>>> We will see! What do you all think???

Edited October 31, 2010 by Kscott12

[jguttery 0]

I have BCBS of Arkansas so my plan my be different from yours, however when I called BCBS they told me that out-patient surgeries had to have a "pre-determination" (their words) however in-patient sugeries did not require a "pre-determination"... so reading what the sent you. When I asked if that ment approval they said.. "it's a determination, not a approval"... lots of whitewash talk. Now there is a pre-certification required and that's probably what your IS is talking about..... just call BCBS and speak with them. I found them more than helpful!!! Best of luck to you!!!!

[Gotta win 4me 12]

I went for Pre-Admittance to day and got all my test done. I went by the metabolic center and let her read the letter and she said that it is indeed an approval letter. She said that my insurance company does not pre authorize out patient procedure. They only pre determain if it is medically necessary. Thanks for all your help!!!

[HappyMom 1]

I received pretty much the same letter from BCBS too. I laughed at it and told my husband wouldn't that be a kick to have the surgery and then they deemed the surgery not medically necessary.

I took the letter to my surgeon's office was adamant that I was approved. I had the surgery and BCBS did indeed cover the surgery. I would listen to the surgeons office. They REALLY want to make sure that the bill is paid. Call BCBS to make sure, but I am sure that all will be well.

Congrats and good luck to you!

[Gotta win 4me 12]

Thanks for the assurance...I wish they would just use the words Approved or Denied!! It would make things so much easier. After I posted the reply. I did give BCBS a call because I know me and a person word other than someone at BCBS is not going to fly with me!! They said that it is approved so I'm extra excited not!!! I'm ready for this to start!!!! Thank again for your help!!!:thumbup: