Does Anyone know About BCBS of NJ

[tina.miller 0]

Hello All,

I am am waiting for the approval of my Lap Band surgery from Horizon Blue Cross Blue Shield PPO. Does anyone know how long they take. It seems like forever I have been Waiting. Everytime I call to see about the update, there has yet to have something documented in their file. Do they have a contact phone number. Does anyone have any information on that Dept. What should I do. Are they good with approving. My Drs. Office says that they faxed over the information on the 24th of January and I have called alomst every couple of days to see if they have received it. What should I do. Someone if you could help me please respond.

[Sugarbear 2]

I have BCBS (Arkansas). They approved my surgery in no time. I got all the necessary information, even letters of recomendation from two doctors. Did that part on my own. My policy pays 50% on Weight loss surgery. So I don't think there would have been any question of approval. Your lap band surgeons office will help you with the required things for insurance. Some require a sleep study, a psyc evaluation. If the insurance doesn't require it the doctor might. I did both. My pcp wrote them a letter promptly also. I don't know that he had to, I just ask him too. If you get everything to them, I doubt it will take longer than two or three weeks. Mine was less. But I got everything done and sent it to them at once. Hope this helps. I will get banded in March.

[stomaszewski 0]

Hello, have you heard from Horizon? I sent you a message but I don't know how this forum works yet. Anyway, I am waiting to hear from Horizon and I was wondering if you heard, how it worked out for you, how long it took...any info you can give would be helpful in keeping me from going too crazy while I wait. :nervous

Thanks so much!

Steph T

[tina.miller 0]

Hello,

Thanks for your reply. I have been waiting, but only because the Drs office that faxed out my paper work has faxed it to the wronf office, so I had to do it myself. If your drs office tells you that they faxed it over, everytime I called a representative they told me there was not phone number for medical policy nor a fax number, it has to be mailed. So I mailed mine this past monday. So hopefully there will be some results. How about you? did they mail it or fax or what? what drs office did you go to? If you find out something before me please let me know, I will also keep you informed, and please you do the same.

[stomaszewski 0]

My dr office is calling in my information today. She said she called to put in the request and then gets transferred to a medical review person who evaluates everything and then gives a response. My dr office told me a good 2 weeks because oftentimes Horizon will ask for additional information. I have the impression that they have dealt with Horizon before, so hopefully they do it correctly from the beginning.

So I am impatiently waiting and hoping everything they will ask for is in and has been done.

I go to Dr. Goldstein in Voorhees...how about you?

Steph

[Alexandra 55]

NJ state law requires a response from the carrier within 30 days, though it usually goes much faster. Of course that's 30 days from the date they receive a complete file, and that's the hard part.

The good news is that Horizon is very band-friendly. If you're medically qualified, you'll be approved. :biggrin1:

[seppi 0]

I have Bc/Bs of NJ, Medallion, I think it's a PPO, I got a response very fast, about 10 days. Everything was covered except the anesthesia. (I think they have fixed the anesthesia part by now.)

[terrriho 0]

I have Horizon BCBS of NJ and they were tough:heh: . I have the traditional plan. They didn't want anything faxed, stuff only moved through their system if I called, after 7 weeks and many calls they finally told me I would need a six month doc supervised diet and then came back 2 weeks later and asked the surgeon for "more infomation" about his program, then seven weeks later finally approved me (what happened to the six month diet:confused: ) but I still had to call them to get that information working through their system. Any way, bottom line is I called a lot and they did approve me I just don't know why it had to take 4 months.:faint:

Good Journey,

Terri

[tigger33 0]

I have the same Insurance you do. I used dr. abkin and Dr. bertha and my insurance came back in 12 days i was so shocked. I thought for sure since I had no comorbidities that they would deny me, but all you have to do is ask. It was very very easy to get them to cover this. I paid nothing but they copay for my surgery and nothing for my fills either. The only bad thing is that they make you wait 90 days in between each fill which sucks. Good luck and I hope you hear the great news soon.

[stomaszewski 0]

Thank you all for the info...I thought getting all of those doc appts taken care of was hard but waiting is going to be torture!

Do you know what Horizon considers "medically qualified"? I have Horizon Direct Access (I guess it's like a PPO...no referrals needed). My BMI was 39.5 at the dr appt but my highest was about 41. I also found out through this process that I have sleep apnea, acid reflux, and high blood pressure (sporadically). I've also joined a nutrition/psych/fitness program required by my surgeon. What do you think?

Thanks,

Steph T

[Alexandra 55]

Thank you all for the info...I thought getting all of those doc appts taken care of was hard but waiting is going to be torture!

Do you know what Horizon considers "medically qualified"? I have Horizon Direct Access (I guess it's like a PPO...no referrals needed). My BMI was 39.5 at the dr appt but my highest was about 41. I also found out through this process that I have sleep apnea, acid reflux, and high blood pressure (sporadically). I've also joined a nutrition/psych/fitness program required by my surgeon. What do you think?

Thanks,

Steph T

It's not Horizon but the AMA that sets the standards for medically qualified. If your BMI hovers around 40 you should be considered qualified even without comorbidities, but your list of conditions will serve to confirm your eligibility. I'm quite confident you would be considered medically qualified.

You will also have to show that you've been morbidly obese for at least 5 years and have tried other means to control it. Exactly how that information is presented may vary from carrier to carrier, and I'm not certain how Horizon requests it. But be prepared with it because it will have to be shown at some point.

If all those points are in order you would be considered medically qualified for bariatric surgery (assuming you pass the psych exam), and if Horizon gives you any push back on that score you have grounds for appeal.

[Sugarbear 2]

Thank you all for the info...I thought getting all of those doc appts taken care of was hard but waiting is going to be torture!

Do you know what Horizon considers "medically qualified"? I have Horizon Direct Access (I guess it's like a PPO...no referrals needed). My BMI was 39.5 at the dr appt but my highest was about 41. I also found out through this process that I have sleep apnea, acid reflux, and high blood pressure (sporadically). I've also joined a nutrition/psych/fitness program required by my surgeon. What do you think?

Thanks,

Steph T

I have never seen so much stuff required ! But if you really want to be banded then you will have to meet their criteria before they will approve you. I already had a history of trying all sorts of diet and or exercise programs. Many of which I was successful, but only short term. Many obese people can do anything short term. It is the long term that comes back to boot us in the butt. My doctors sent a letter to my insurance stating that fact. More often than not I put the weight back on and then some. This is why I chose to get the band. I needed a tool to help me long term. Some can go to groups that educate you on weight loss, nutritution, exercise, ect. and it seems to help them long range and they do not have to take drastic measures such as I did along with many others. If you can do that it is wonderful. I couldn't. So good luck on your venture, what ever it is. Stay in touch and let us know how things go for you.

[Sugarbear 2]

Oh, by the way, I just got banded Wed. Woohoo!!!!!!!!!!!!!

[stomaszewski 0]

Tina,

I was wondering if you heard anything yet? I am still waiting and trying to find out if my doc office even called in my information yet. This is very frustrating because I've been done my part for over 2 weeks now. I am very impatient now that things are out of my hands!

I was just wondering what your status was. Also, can/will the insurance company give me approval status if I call?

Thanks!

Steph T

[Alexandra 55]

StephT (and everyone else):

You can absolutely call the carrier to find out if they've received everything they need. This is crucial! So much time is wasted because someone didn't get a fax or something--it is your job to check on things and make sure they are moving along.

Call member services and say you want to find out if a request for preauthorization of surgery has been submitted, and what the status is. OF COURSE you have the right to ask!!!