BCBS How to find your requirements

[beachgurl84 456]

Hi Everyone,

I have BCBS NC and as of yesterday they have eliminated to 6 month diet requirement. That's right, NO TIME LINE!!! I had a really hard time getting details when I started this journey on what my plan required for approval but I finally did. I thought I'd share how you too can get your medical policy detailing the requirements if your searching through "mud" like I was. It's pretty simple (but takes us forever to think of it).....

Google "BCBS SA (state abbreviation) Corporate Medical Policy". This should take you to a page that list all the medical procedures covered by BCBS in your state that have approval requirements. In NC it's listed as "Surgery for Morbid Obesity" but I know in CA it's listed as "Bariatric Surgery".

So search the list for one of the names (Might be "Weight Loss Surgery", who knows). Your policy will start out describing the various types of procedures covered (i.e. bypass, sleeve, lapband) and then it will list the details of the approval criteria in the Policy Guidelines section.

One thing I noticed with the NC policy when I found out it might be changing....the last review date was June 2013. They review yearly. However, they did the review in June, approved the change July 1, and made it effective July 15. So if your review was over a year ago, you can probably expect a new document soon that may have different requirements.

Hope this helps!

[Bufflehead 6,358]

This is great advice but just a tip - people also need to check if there are any special requirements for the policy as adopted by their employer, assuming the policy is from their work. Sometimes there are special modifications on a by-employer basis. Just for example, I work for the state of Tennessee, and BCBS is one of the insurance options offered by the state. However, our policy has different requirements for bariatric surgery than the standard BCBS requirements. These are laid out in our member handbook.

[jlj1110 49]

I am also with BCBS of NC and was so excited when I heard this last week. I was already 5 months in, but at least now I was able to have jumped through the last hoop, and have my stuff submitted! Now I hope they quickly give the approval so I can start my two week pre-op liquid diet.

Anyone else going through BCBS NC that can share how long it took for approval once the dr office submitted documentation? I am a teacher, so I am hoping I can have the surgery and have a little time to recuperate before school starts.

Thanks!

[Displaced Va Girl 23]

Bcbs of NC may have dropped their 6 month diet & exercise but bc I was denied in May I still had to finish it (grandfather rule I guess). Now I just got another letter of denial bc I didn't follow the bariatric requirements (I was banded in 2008) but they won't explained to me what they are. They are doing their best not to pay for these surgeries in hopes you will give up the fight. DONT GIVE UP! Good luck

[KatieD6982 68]

Thank you for this post!!! I FINALLY was able to locate my policy regarding Bariatric Surgery!!! Anyone else have Highmark BCBS Select Blue or BCBS of NE PA?

[Forsythia 882]

You can always call them too. That's what I did. I tried to find out via the BCBS IL website but finally I just called them on my lunch hour and got confirmation of their policy for my PPO that way. I suppose I could have hunted them down. I know exactly where the BCBS IL building is here in Chicago! LOL. It's right next to the Aon center, which is the building I used to work in!

[beachgurl84 456]

You can always call them too. That's what I did. I tried to find out via the BCBS IL website but finally I just called them on my lunch hour and got confirmation of their policy for my PPO that way. I suppose I could have hunted them down. I know exactly where the BCBS IL building is here in Chicago! LOL. It's right next to the Aon center, which is the building I used to work in!

@@Forsythia,

I called at first and the customer service rep told me there were no requirements and I just had to meet the BMI requirement. They had no idea what I was asking for. I specifically asked them "is there a 6 month pre-op program requirement." They said no. I didn't trust their answer so I called a week later and asked to speak to someone in prior review, that's when I learned BCBS NC did have a 6 month requirement (this was before the policy change), and the psych & NUT requirements. So when you call to ask, ask them to email you the corporate policy or direct you to it. That's what the guy in prior review did which cleared everything up.

[beachgurl84 456]

This is great advice but just a tip - people also need to check if there are any special requirements for the policy as adopted by their employer, assuming the policy is from their work. Sometimes there are special modifications on a by-employer basis. Just for example, I work for the state of Tennessee, and BCBS is one of the insurance options offered by the state. However, our policy has different requirements for bariatric surgery than the standard BCBS requirements. These are laid out in our member handbook.

@@Bufflehead,

Good point. I carry my own insurance so I didn't even think about it being different through an employer.

[Sleevarilla 169]

My process with BCBS of NC was very, very smooth. I was submitted on a Thursday and approved the following Monday! I'm very happy they dropped this requirement!

[Pictou 12]

You need a copy of your EVIDENCE OF COVERAGE (EOC). Every health insurance company has one that is unique to your group or individual policy. Call customer service and request a copy ASAP. Some will mail a copy, others will send a PDF. Most medicare related policies are required to send a hard copy.

Then you have to sit down and read the section on bariatric surgery, the section on appeals policy, and the exclusions. You should have 5 appeals, the last two of which will should decided by an independent review committee usually a state official.

If you work for a huge company or state or county government it is possible that the company or government officials are setting the policy. That's because these entities are usually self-insured. This means they pay their own claims and just pay the insurance company to administer the claim. That also means if your insurance is State of XX insurance by Aetna/Cigna/UH/BCBS your requirements can be different from someone who has a personal or small group policy with the same insurance company.

I can't answer questions about specific policies. My experience is proof reading and printing copies of policies.