Who do I need to ask for?

[Krisbell 26]

As of yesterday, I finished all of my requirements to submit to insurance for pre-certification. The lady in the nutrition class said that from yesterday it takes up to 4 weeks to have surgery.

I have already done my 6 month weigh ins, my psych eval, my nutrition classes, my stress test, breathing exercises and EKG, and h pylori test.

I had some issues with my surgeons office because they did not want to submit everything to insurance and wanted me to start over because I had missed my November's weigh-in with my primary due to scheduling reasons because of Thanksgiving holiday. Needless to say, I wasn't just frustrated, I was pissed too, so I called my insurance BCBS of AL and they told me that yes they want 6 consecutive months but if I could get my primary to write a letter explaining that I wasn't seen in November due to thanksgiving and i got in within a week that I should be okay.

So, I'm going to call BCBS in about a week to see if they've received everything and if I have been pre certified yet, but I don't know who I would need to speak with. Should I ask for a claims representative or should i ask for whoever approves surgeries?

Also, if for any reason I am denied, how can I appeal my case considering that other than that one month that I was seen within 5 days of when I usually am seen, how can I turn around and get it approved?

[MowryRocks 679]

The customer service reps are used to this type of question and they can get you to the right person. I have UHC, but I got my answers that way.

[SBowen135 28]

I have BCBS and I also had to go through a six month process in which I attended classes, had visits with my surgeon, as well as had to have visits with my PCP. I'm not sure about yours but the way mine worked was that the dates of my classes and visits so long as I followed the guidelines of being seen every month, but as I understand it you were not seen in November due to holiday scheduling so maybe if anything they will count your December visit as the next month and then you will just have to go an extra month to make up for the November visit missed. If your insurance is anything like mine you will probably need to talk with someone in authorizations just because that's the area of the company that approves the surgery and would have a better idea of the situation. My surgeon's office sent my information in on Friday February 24th and I received my approval on the 28th, which shocked me because I expected it to take longer, but I called and spoke with someone in authorizations and they told me that it only takes 2 business days. So I would definitely call them. I wish you the best!

[trekker954 421]

Bcbs want the months consecutive and are pretty anal about them. My hospital also made it clear weigh in more or less had to be every month, not three weeks, not five or six weeks but monthly. Maybe with a holiday you could get by with the closest date but not skip an entire month. Maybe if you can provide them airline or hotel receipt showing you were gone an entire month. But to start over, ugh. Good luck
Bcbs approved me no problem.

[LeaninLanc 83]

I have BCBS of MN and they required six months but only three had to be consecutive (in the event a scheduling issue arose). My doctor's office was slow to handle most paperwork issues including submission. I made it my "job" to call the office person who handled insurance submissions as well as the insurance co to find out if/when it was submitted. I was pleasant but persistent. It was so frustrating to do everything that was asked of the requirements and then know the paperwork was sitting on a desk. I had my surgery 6 weeks after completing my last 6-month visit. I just had surgery 4 days ago.

[Krisbell 26]

My surgeons office submitted everything on march 1st, including the detailed letter from my primary explaining that they were closed the week I normally see them.

on march 6, I got the phone call that they did APPROVE me. So I think every insurance is different, but if anyone ever has to deal with what I did, make sure you get a detailed letter explaining why you missed a weigh in that month