Tricare standard requirements

[thaskett 1]

Hello, I am new to the forum and needing advice. I have tricare standard north region. BMI is 45 and I have hypertension. My surgeons office indicated that I needed to go through a 6 month doctor supervised diet to get approval which was fine but tricare has denied to pay for these visits. They cost $165 each month and I cannot afford to pay this out of pocket. My question is this- why can't my surgeons office just submit my paperwork for approval without these 6 months of doctor visits? I have all of the other tests completed for approval. Are these doctor visits for the surgeons or is it a real requirement for tricare standard? I am wanting to call my surgeons office and tell them to go ahead and submit what I have now. Any suggestions or thoughts? Has anyone else had this issue? Please advise Tracy

[Nycole 0]

I have Tricare also. I have Prime though. I had my surgery in Nov 13th. The 6mo of a supervises diet is a huge requirement by Tricare. Without it, it will be denied. The way around paying for it out of pocket is to just see your PCM and talk about weight loss each month. Have them give you a plan to follow bad if it doesn't work to talk about trying something else the next month. That's what I did. But they need to keep detailed notes. While seeing your PCM, it counts. That's how I got mine. The surgeon submitted my paperwork at 1:00pm and by 2:30pm Tricare called hem to approve it.

[mgrymonprez 1]

I am also seeing my PCM for the six visits. I started in nov. the PCM kept telling me I didn't need to so they looked up tricare info and it said you did. Hopefully I'll be able to get it in April or may.

[glc111 4]

Does anyone know if there are any out of pocket expenses with Tricare Standard??

[ArmyOfMe 82]

I have Tricare Standard, as well. The Tricare Rep told me that my PCM has to send a letter of medical neccessity to Tricare and they will approve ot deny my request for GBS. She also mentioned that if my BMI is under 40, I am required to have at least one or two co-morbidities. For BMI of 40 and up, the chances of approval increase. The lady also mentioned that a 6 month diet is not required by Tricare but it's at the surgeon's discretion. I don't know if this applies to Standard only - this still confuses me.

I have no idea about any co-pays other than the 15%-25%.

ETA: Typos

Edited February 20, 2013 by Em1

[ArmyOfMe 82]

I don't want to start a duplicate thread about the same topic Ticare Standard Requirements but I would also appreciate some input from those who underwent GBS under the Standard Plan.

Here is my confusion:

1st Tricare Rep said I do not need referrals nor a PCM to write anything. Just to go ahead and schedule an appointment with the Bariatric surgeon in network. No 6 month diet proof, no diet history.

2nd Tricare Rep said I do not need to show a 6 month diet proof but I do need a Letter of Medical Neccessity from my PCM sent to Tricare for pre-approval and Tricare sends me a list of their choice of Bariatric surgeon to colaborate with.

3rd Tricare Rep said I do not need a PCM, do not need any referrals, do not need diet proofs. Just to constact the Bariatric surgeon in my network. Also, Tricare does not have any documents, manuals, broshures specifically for Bariatric Surgery.

If I call a 4th time and get another different answer about their requirements, I am going to strangle someone.

Anybody had GBS with Tricare Standard Plan and can give me/us some real facts? Any details are appreciated!

[sapperwife26 7]

See your PCM every month for six months or you may be able to find a RNY education group you can see either through your surgeons office or at your surgeons office. I did that and it worked.

[hittpants11 18]

When my husband and i got married and he did all the paperwork on base, i automatically was put on Tricare Standard. I swtiched myself fom standard to prime when i started researching bariatric surgery.

I just had my first appointment to get a referral to a surgeon. So I guess I will find out just how smooth Tricare Prime is.

[loveme0629 15]

I don't want to start a duplicate thread about the same topic Ticare Standard Requirements but I would also appreciate some input from those who underwent GBS under the Standard Plan.

Here is my confusion:

1st Tricare Rep said I do not need referrals nor a PCM to write anything. Just to go ahead and schedule an appointment with the Bariatric surgeon in network. No 6 month diet proof' date=' no diet history.

2nd Tricare Rep said I do not need to show a 6 month diet proof but I do need a Letter of Medical Neccessity from my PCM sent to Tricare for pre-approval and Tricare sends me a list of their choice of Bariatric surgeon to colaborate with.

3rd Tricare Rep said I do not need a PCM, do not need any referrals, do not need diet proofs. Just to constact the Bariatric surgeon in my network. Also, Tricare does not have any documents, manuals, broshures specifically for Bariatric Surgery.

If I call a 4th time and get another different answer about their requirements, I am going to strangle someone.

Anybody had GBS with Tricare Standard Plan and can give me/us some real facts? Any details are appreciated![/quote']

I have tricare standard I started the process feb 5 2013 my surhery is march 7 2013. I have tricare standard all they wanted from me was two years of medical history showing BMI t hat took me one week I went to VA for 2011 record went to pcp for 2012. My doctor wrote a letter od medical necessity high blood pressure pcos I was approved. Only out of pocket expenses are 1200 for nutrition and my cap for hospital stay which as of now is 500 yes tricare has a 20 page pamplet on it. If you have standard you can go to anyone who takes tricare

[kraney 219]

I have Tricare prime. I have a military hospital close by, William Beaumont army medical hospital. Going through my PCM with a referral for bariatric surgery at the army hospital I have no copay. I have only had to attend an informational meeting which included info on the three surgeries they offer, as well as meeting with the nutritionist in the same meeting. I also had to attend one support group meeting, and do a psych eval off base (also no copay). After that surgery has been scheduled. I started the entire process on jan17, and surgery is scheduled for mar 14.

[mrhinebolt 30]

I have Tri care prime.....called PCM asked for a referral and was approved within 5days....made my first appointment for orientation which is the mandatory first step...this was scheduled on oct 25th 2012.... Next day did labs,X-ray and EKG ....then was given a paper with steps to follow. Step one physic evaluation...step two nutritionist ..... If you pass those two steps then step three is decision appointment with surgeon. Decide what type of surgery would be best for you. That day I received surgery date. One final appointment two weeks before surgery for weigh in to make sure you haven't gained any weight....if you do you have to wait 6 months and start the steps over. At final weigh given instructions for two week liquid diet....... Then show up on surgery date. My journey began October 25th 2012......Surgery day march 27th 2013... So 5 months for me....hardest part was getting appointments that worked with my schedule.... That added some time.....I will have follow up appointment and lab work for the next 5 years...but the will start 2 weeks and progress to just once every 6 months. I am fortunate to live in Virginia at the largest military installation,,,,,, so my surgery and all follow up will be done at the naval hospital. Hope this info helps with any of y'all that have Tri care prime. The cost of my surgery was zero. The only cost have been shakes for liquid diet and Vitamins. Found most at the exchange and commissary .....so I have been very blessed. Good luck to all and God best.

[ArmyOfMe 82]

This is all good info to keep in mind. Thank you, ladies.

I got my PCM to work on the Letter of Medical Necessity to be sent to the Bariatric surgeon. I am still waiting for her office to call me about the Orientation meeting (I think that's what it is called). Meanwhile, I had an EKG and lumbosacral spine x-ray done and I am expected in two weeks for lab work and Echocardiogram.

My biggest problem is the fact that I will be moving in 4-5 months to the West region and I am scared the surgeon will reject me since I won't be here for the long term follow-ups with him. I would like to have the surgery where I am at right now because I have a strong family support here who can help me and care for me and my child.

Is it possible to continue the aftercare with a new bariatric surgeon at the new location and have him send regular updates on my progress to the surgeon who did the surgery?