Bcbs of NJ requirement

[nancytole 4]

Below is part if the letter the insurance company sent me as far as the pre op requirements. I want to be sure I get this right the first time.

I have 6 months of supervised by my physician (pcp) weight loss. It was within the last 12 months. According to the letter does this full their requirement? Also, the pcp is going to document this pre op requirement by sending in one of the progress note saying something like "Patient has attempted physician supervised weight loss within the last 12 months for 6 consecutive months. She has lost 14 lbs during this time." Has anyone dealt with this with Horizon? What do they want specifically? My pcp says I am overthinking it and he has done it this way many times before. I just want to be sure all my ducks are in a row. I'm

So close, I don't want anything to hold this up

Thanks!

As per your request, please find the necessary documentation required with the Predetermination Request for Bariatric Surgery. Within the 12 months prior to the time of surgery, the patient must meet all of the following requirements: 1. Documentation of successful completion of at least 6 consecutive months of supervised conservative weight loss program, diet programs/plans (e.g., Weight Watchers, Jenny Craig), or the Horizon Obesity Disease Management Program. ​Successful completion means: • weight loss or at least maintenance of initial weight prior to participation of the program; and • photo-copies or print-outs of progress notes or formal documentation of at least monthly follow-up by the supervising physician, other health care provider, or program coordinator including the patient’s weight and progress relative to the goals set at the start of the program. NOTE: Pre-printed check-off forms and summary letters are NOT acceptable documentation for this requirement.

[SassyTink 78]

Nancy try to get a copy of your entire policy regarding Bariatric Surgery through you HR or through BCBS of NJ.

I went through hell. If you want to read my story go up to the search box above and type in BCBS of Illinois, I can't believe it.

My advise to you is knowledge is power......read your entire policy so you know what they cover.

Sassy

[Tikvah 70]

I have Horizon (PPO, not an H.MO) and I didn't need to do that (12/18 surgery, was approved in November).

All my bariatric center sent in was:

5 Year Weight History + BMI at first consultation.

3 NUT Visits

Psych Evaluation.

I didn't even have a PCP at the time of meeting the Surgeon.

Edited January 5, 2014 by Tikva

[donaboss 131]

Hmm I had horizon and I did not have to do that.

[nancytole 4]

Maybe I will speak to my surgeon's office

In Monday. At their seminar I went to, the surgeon said that the office would take care of insurance. I tend to overthink things and I obsess. Lol. I know when you call the ins co you can get a different answer every time.

[donaboss 131]

Maybe I will speak to my surgeon's office In Monday. At their seminar I went to, the surgeon said that the office would take care of insurance. I tend to overthink things and I obsess. Lol. I know when you call the ins co you can get a different answer every time.

Who's your doctor? I would suggest when u go see him that you ask. When I went for the first time I sat with the coordinator and She gave me a list of requirement for out insurance. It's way shorter than that letter. Honestly it was soo easy.. And my BMI was a 37 which they require a 40 and I got approved in 8days including weekend. My doctor said this is the easiest insurance to get approved, unless, your job didn't want bariatric surgery on it... Good luck

[nancytole 4]

Dona. I am in RI. My doc is here in RI. The ins is through my hubby's work. From what I am reading in that letter the ins co wants monthly progress notes. Not just one with a summary. It's kind if vague.