Prior Authorization?

[Allibrooke28 0]

Hello,

I am new to this whole process, and I need some advice or insight into the whole insurance thing. My pcp recommended I look into surgical options because I have struggled for so long with my weight. I cannot afford to have surgery if my insurance does not cover it, so I called right away. I was told it was covered, with an in network dr, with prior authorization. I was pleased, but unsure about what the requirements were. I went to the informational seminar yesterday, and was given the packet of info including all of the questions to ask insurance. I called and talked to another rep who verified what the previous rep had told me. I went on to ask if a medically supervised diet was required, and she said she was looking that up. She comes back, and tells me that Bariatric surgery or any weight loss related services are not covered. Wth?! I am so confused, and don't know if that means they are trying to discourage people from trying to get surgery so they don't have to approve it or will it not be approved no matter what? Why would two people tell me it was, in such detail? They both even told me about deductibles and out of pocket costs. I am so disappointed and don't know where to go from here.

Thank you in advance for any advice!????

[becomingmandikaye 262]

You should be able to find your insurance provider's policies and coverages online so you can have that information when you call and talk to them.

What insurance do you have?

[2goldengirl 2,076]

You can call back and ask to speak with a Supervisor. Explain that you got two widely different answers on two phone calls and ask for clarification.

If, in fact, your particular policy excludes coverage for bariatric surgery, that means it won't be approved for anyone, under any circumstances. That's what an exclusion from coverage means.

If it's covered, then ask to be sent a copy of the criteria that need to be met for surgery to be approved.

I hope this helps!

[KristenLe 5,979]

Talk to your benefits coordinator or insurance agent! Often times the Reps are wrong - so you need to find out which one gave you the wrong answer.

[Allibrooke28 0]

Thank you for your replies, I really appreciate it.

@becomingmandikaye: I have Premera Blue Cross Blue Shield of Washington.

I just don't know if it is a complete exclusion, no matter what, or if there are medical exceptions to the exclusion that can be approved if you meet certain criteria. Has anyone had any experience with this situation?

Edited May 6, 2016 by Allibrooke28

[Womanvsmirror 314]

Do you have or can you create an online log in for your insurance? If so most if not all companies have their clinical bulletin posted. I know with Aetna even though the details are spelled out you still have to ask your policy. Some employers exclude wls to get a lower rate. But if is discovered that its an exclusion, then that's what it is , no special circumstances. If its covered that does not guarantee surgery , you would then have to go through the requirements and submit for approval.

Thank you for your replies, I really appreciate it.

@becomingmandikaye: I have Premera Blue Cross Blue Shield of Washington.

I just don't know if it is a complete exclusion, no matter what, or if there are medical exceptions to the exclusion that can be approved if you meet certain criteria. Has anyone had any experience with this situation?

[Acceber12 5]

Hi @@Allibrooke28, I'm in Washington too! I think the best bet is to get the Plan Document. This should spell out the terms and conditions of your plan, including whether WLS is excluded. If your health insurance is through work, you can request the Plan Document from your work's HR person. Everyone's plan is different and has different prerequisites for getting insurance approval.

Sent from my iPhone using the BariatricPal App

[Deletemyacct 39]

I read online some employers can op out of offering that benefit, it makes the plan cheaper. I recommend contacting your benefit person at work.

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