UHC Approval In 3 Days

[CurvyCakes 269]

As my surgery date got closer the excitement was building rapidly but when I when I returned from lunch and received the email from my surgeon office that I was APPROVED......omg I LITTERALLY was jumping up and down and yelling THANK YOU JESUS!! This journey at times has been tedious but well worth it. Things became very real once I received the approval. I am so excited yet nervous but I know these are normal emotions.

[bravobentley 55]

congrats!!!! that is incredible news thank you Jesus indeed

[CurvyCakes 269]

Thank you. During the 6 month supervised diet I never considered I could be denied but reading folks stories of how they were denied sent me into a panic. Thank goodness they approved me quickly I'm sure I was driving my family insane lol.

[theard 5]

@@CurvyCakes Do you know what reasons they do not approve people?

[theard 5]

@@CurvyCakes BTW CONGRATS!!!

[CurvyCakes 269]

<p>@@CurvyCakes Do you know what reasons they do not approve people?</p>

Depending on each persons situation and insurance it was various things. It seemed some insurance companies requires them a BMI of 40 without comorbidities or 35 with them but also a5 year history of being morbidly obese.

I know for myself that sent me in a panic as my weight has fluctuated between BMI of 37-43 over the last several years so if that 5 year history applied to me I was dead and stinking and would not landed me a denial. Thank goodness my UHC wasn't structured that way.

[allycatt98 35]

<p>@@CurvyCakes Do you know what reasons they do not approve people?</p>

Theard,

I was a Pre-Auth Nurse so I will share what I know about the process.

1. Some offices try to flood you with paper (labs, office notes, imaging, etc.) -- it's annoying and it doesn't help the patient's chances for approval. I couldn't stand it. Seriously, 100 pages! How about giving me the info I need to make a decision?

2. Missing/Incomplete documentation: All the required documentation must be submitted. If five years of documented weight loss is required, then that's what the nurse is looking for. If there is a nutritional counseling requirement, then the nurse is looking for complete records from the practitioner that include diet, exercise, etc. You'd be amazed how many people miss this one. The NUT and Psych documentation must include all the elements required by the insurance company. Many of the commercial plans have templates available that you can give to your practitioner.

3. Medical Necessity isn't met: This one is a biggie and will often cause an immediate denial. Those letters of medical necessity that the docs send in are often a waste of time and are usually only useful at the time of an appeal. If criteria isn't met, then your Doc needs to be prepared to discuss the reasons why you need the surgery with the health plan's Medical Director. They can call in while the case is being reviewed or do a peer-to-peer review after it is denied. Basically, the doc has to care enough to prove your case. Some do, some don't.

Hope this helps. Let me know if you have any questions.

P.S. The 30 day timeframes a quoted are BS.

Medicare: 14 calendar days for standard (non-emergent) requests with an additional 14 calendar days if an extension is granted because it is in the best interest of the enrollee; i.e. additional time to submit required documentation or have tests done to meet criteria. The health plan is required to advise you in writing if an extension is needed AND you have the right to file a grievance if you disagree.

Medicaid: every state is different (i.e., New York and Missouri require a three business day TAT. But if additional info is needed the NY cases are allowed to go up to 14 calendar days). The default for all Medicaid states is typically 14 calendar days. Some states require an even shorter TAT as mentioned. Even if an extension is granted it is typically only for up to 14 calendar days.

NCQA accredited health plans: If the TAT criteria listed above does not apply (i.e. Commercial Health Insurance) then check the plan's accreditation. NCQA requires a no more than 15 calendar day TAT with an additional 14/15 calendar days if an extension is granted. However, you still have to be notified in writing than the Health Plan granted an extension AND the notice should specify why it's being granted.

I know I typed a lot. Hopefully it helps. Sorry for any typos, I'm on my iPad.

Ally.

[theard 5]

@@allycatt98,

Thank you. That was very helpful information! If the Dr office is missing documents, basically the insurance company will not approve the surgery? If they disapprove it, will I be able to appeal the decision? This is scary bc I have to follow this 6 month process and not even knowing if I'll be approved or not. I just hope I have all that I need when that time comes.

Again, thanks for the info!

[allycatt98 35]

<p>@@allycatt98,</p> <p> </p> <p>Thank you. That was very helpful information! If the Dr office is missing documents, basically the insurance company will not approve the surgery? If they disapprove it, will I be able to appeal the decision? This is scary bc I have to follow this 6 month process and not even knowing if I'll be approved or not. I just hope I have all that I need when that time comes.</p> <p>Again, thanks for the info!</p>

Yes, as a member you have the right to file an appeal. You can also give your physician the right to file an appeal on your behalf. But positive thinking! If you are concerned about the approval process, keep track of your documentation throughout the process. Know the requirements and read up on their review process. If there is a specific format they want for the NUT counseling and psych visit make sure that's what they get.

Every review process is different. Some plans will contact the doc for the missing information. Others will just issue a denial. The plan I worked for had millions of members so their volume was ridiculous and it often did take the full 14 days for review. If we were at the TAT deadline, then typically a denial was issued for missing information. But... The doc still had the ability to request a peer-to-peer review with the health plan's doc to discuss the request.