BCBS Insurance/attorney question

[Lisa1996 24]

I had my consultation a couple weeks ago. My surgeons office sent in for approval and have not heard back yet. I know they will deny the first attempt, as this is the only way for the surgeon to find out what specific criteria I need to meet. We have tried and tried to find out what criteria I need to meet, but the only thing they will tell me is that we need to submit and they will enter it into InterQual smart sheets (So much for transparency). I'm wondering if it is a good idea to just have my attorney write a letter right away? I realize I am getting ahead of myself, but already they have been a pain to work with. Has anyone here had any luck hiring an attorney to help them advocate their appeal?

[kaitlynm 335]

Which state is your BCBS out of? Mine is out of TX and I called them and they told me where to find everything. Maybe you just got a bad rep. I had to have a nutritional consultation, psyche eval, letter from my PCP and I think that was all. BCBS of TX requires no pre diet, and neither did my surgeon. It took about 3 weeks to get the 2 appointments completed and then they took 21 days to approve me. Surgery was 2 weeks later.

[Lisa1996 24]

It's out of Iowa. I have tried several times to find out what I needed, and the surgeon has also tried to get a straight answer, with no luck.

[kaitlynm 335]

Is it on their website? I had to do some looking, and with the help of the rep, I could pull up the whole policy and all of the requirements.

[Lisa1996 24]

Unfortunately Wellmark BCBS has zero criteria listed online. I will continue to press them until I get something that resembles an answer. Talking to them is beyond frustrating, although I will say everyone I have spoken with has been very pleasant, but not at all helpful. I think part of the issue is the plan is technically funded by my husbands employer, so BCBS is essentially a middle man for claims.

Edited March 29, 2016 by Lisa1996

[UsernameTaken 283]

I just tried to look up the benefits for this insurance it is very weird, doesn't mention any requirements pretty much states prior approval required and they will determine if it's medically necessary. That's a tough one

[Lisa1996 24]

It is very weird. That's why I am contemplating getting my attorney involved from the beginning. It's like pulling teeth to get an answer.

[UsernameTaken 283]

Does it say anywhere how long they have for review?

[UsernameTaken 283]

I think you might want to consult with Lindstrom associates they deal with bunch of these type of cases and appeals they might help, I hear good things about them on forums

[Lisa1996 24]

I will check them out! We have prepaid legal benefits through my husbands employer. I will probably have them send a letter to BCBS (at no extra cost to me). Perhaps that will be all I need to do to get light a fire under them.

[ising4godinohio 8]

It's out of Iowa. I have tried several times to find out what I needed, and the surgeon has also tried to get a straight answer, with no luck.

Go to their website. Look for a link that says providers. Click on that. Depending on the site, you might need to enter the state your policy is out of and click enter. Once you enter the provider portal, look for something that says medical guidelines. Then look for a way to search that part. You might have to click around a little. Once you find the search tool, enter bariatric and click search. That will bring up their specific guidelines for wls. However, please be aware that if wls is a stated exclusion the odds of getting approved are extremely slim. Unless your policy is through a self funded employer. Then you might be able to get the employer to ask for an exception

Sent from my SM-G925T using the BariatricPal App

[FreeTheSkinny66 9]

Go to your husband's employer!! Contact the Benefits Coordinator for his employer and request a copy of the Plan Document. As an insured, you are entitled to this document, as it lays out what is covered what is not, etc. I just had a similar situation with United Healthcare - I asked multiple times for thePlan Document and they just kept telling me to go to the employer. I did and got it within 15 minutes.

Good luck. This can all be SO frustrating!

[Lisa1996 24]

Thank you for the responses! You all are amazing! Unfortunately every link brings me to the InterQual guidelines- which require a user name and password (my username and password do not work) to be used only with participating providers. http://www.wellmark.com/Provider/MedPoliciesAndAuthorizations/PreService_InterQual.aspx

I have confirmed that bariatric surgery is covered under my plan. Do you think the plan document will have the criteria or just spell out that it is covered? In any case I will request a copy. The reluctance with information on the part of BCBS is unsettling.

Edited March 29, 2016 by Lisa1996

[littlered12973 5]

Just so you know, I have BCBS in California. It was approved within 1 week. I had 29 days between my consult and sleeve procedure. I had mine 4 days ago. I stayed 3 nights in the hospital and the whole thing was that I couldn't pee. I came home with a cathadure bag. All is good. Not much pain and I walked my rear off down the hospital hallway.

Sent from my SM-G900T using the BariatricPal App

[Lisa1996 24]

thank you littlered1293, that is reassuring to hear. I think we are finally getting some answers, I need 3 diet visits and a psych exam. I am still a little nervous because I am right at the cusp of a 40 bmi. there were times in the last few years I had dipped below. Do you mind me asking what your bmi history was? Don't feel obliged to answer that if its too personal.