Tricare Approval or Denial??

[mmmorgan 0]

how much do you weight and how tall are you? And are you basing this off the Metlife chart? From what I've heard, Tricare is pretty strict about the 100 pound weight requirement. I know some people on here who gained a few pounds or wore ankle weights when they weight in to secure that requirement, you might look into that.

I am 5"2' and about 226.

My bariatric drs. office said they submitted my claim to my insurance last Friday. Still haven't heard anything and nothing has popped up on my insurance website about the claim yet. I guess I just sit and wait.

[mmmorgan 0]

I am 5"2' and about 226.

My bariatric drs. office said they submitted my claim to my insurance last Friday. Still haven't heard anything and nothing has popped up on my insurance website about the claim yet. I guess I just sit and wait.

Or just call Tricare to see if anything is pending. Nope, nothing has even been submitted yet from my surgeon. UGH!!! Now I'm waiting for my drs. office to call me back. I need to find out what's going on here.

[milwif 0]

Or just call Tricare to see if anything is pending. Nope, nothing has even been submitted yet from my surgeon. UGH!!! Now I'm waiting for my drs. office to call me back. I need to find out what's going on here.

Morgan- It seems to me like you have a good chance at getting approved, and if you don't, I'm sure you could appeal it and get approved.

Dr's can be so frustrating can't they? My surgeons office took forever to collect all the information and send it out. The good news is, once it's submitted Tricare doesn't take long to respond!

[mmmorgan 0]

Well, my stuff was finally submitted to Tricare on the 4th. My Upper GI was already approved by last night. Today it shows "Pending Review." OMG, I'm so nervous. My dr. said I could have my surgery as early as next Wednesday. Just have to sit and wait.

[mmmorgan 0]

Morgan- It seems to me like you have a good chance at getting approved, and if you don't, I'm sure you could appeal it and get approved.

Dr's can be so frustrating can't they? My surgeons office took forever to collect all the information and send it out. The good news is, once it's submitted Tricare doesn't take long to respond!

So how long did it take? My husband is leaving for deployment on the 20th and my surgeon only does surgeries on Wednesdays. That means if Tricare approves it, I could get it done next Wed. I am so nervous. I'm really hoping this gets approved the first time and quick.

[milwif 0]

So how long did it take? My husband is leaving for deployment on the 20th and my surgeon only does surgeries on Wednesdays. That means if Tricare approves it, I could get it done next Wed. I am so nervous. I'm really hoping this gets approved the first time and quick.

I'd say not longer than one week. Mine took 3 days I think.

[hope2bthinr 0]

I'm going through this stuff with Tricare too. Tricare told my surgeon's office I didn't need pre-auth because I had other insurance and even gave them a authorization #. Then today I called because the website said NOT APPrOVED, but I think someone made a mistake... I'm 5'1", 226lb and small frame, that makes me 200% of my ideal weight between 106-118. My denial said "did not prove medical necessity with the 100lb over + 1 comorb or 200% of ideal wt", that's according to the girl I talked to so I'm thoroughly confused. I think they did not read "small frame" in my file when they reviewed it and I double checked with my surgeon's office to make sure they stated that. Even my primary said I fit small frame. This is such a run around!! Every person you talk to at Tricare gives a different song and dance. One will tell you approved and the next will tell you something completely opposite. I don't even trust that if I get to approval that they will actually pay.

First they said they had to wait for the letter from my primary ins saying whether they'd pay or not, that was a full week when the darn exclusion letter was in the original package of stuff they received. NOW I get to wait some more to either figure out the mistake or file an appeal and wait, and wait, and wait..... any suggestions?

I'm on oxygen at night because of sleep apnea, not the obstructive type, have bad asthma and fall asleep during the day at work daily, back pain, foot pain, stress incontinence, and I feel like I'm strangling by my own fat when I sleep!! I can't believe I have to be heavier to qualify! good grief, I'd never make it through this process all over again. THIS IS SO FRUSTRATING! I'm having the surgeon's office call Tricare in the morning to see what exactly they were looking at and considering when they reviewed it for approval. It's just ridiculous how you can call and get a different answer each time. I don't know what to believe.

Edited September 9, 2009 by hope2bthinr
clarification

[ruffcat 0]

my paperwork was submitted on August 7th to Tricare.. It was approved August 10th ( over a weekend, Friday being the 7th, Monday the 10th ).. Surgery on the 17th!.. You can call tricare anytime.. find out if there was anything submitted.. good luck!

[hope2bthinr 0]

Yippee for you!! Glad yours went so easy. Calling for info isn't the problem, I've made about ten phone calls to them already...getting consistent answers to questions that make the difference between $2000 out of pocket or $25000 out of pocket, is the problem.

[ruffcat 0]

Lets see if this helps... I am 100 pounds over weight, I am diabetic, high bp, high cholesterol, chronic lower back pain, suffer migraines... I am at 100% pay w/tricare prime. Husband active duty... Tricare paid the whole kit and kaboodle.. If your not getting str8 answers, or consistency.. ask to speak to a supervervisor.. pls let us know how you are doing

[hope2bthinr 0]

Thanks, puts it into perspective, but I meet the 200% of ideal if they looked at it the way it was supposed to be submitted (small frame). Other than that I guess I'm too healthy since I haven't (fortunately) developed all of those obesity related issues (no offense intended, please!). I submitted my family history that shows parents and 7 siblings have heart, obesity, diabetes and high blood pressure, but I guess unless my body actually suffers damage and ends up in that boat, it doesn't matter. I'll be talking to them some more today and will take your suggestion to talk with a supervisor if I don't get it corrected through my surgeon calling.

I would say you're lucky to be approved but I know you'd rather not have the health issues you have that qualify you, or the weight problem. I'm just frustrated. I walk every day even though my feet are killing me and I've tried every diet program under the sun and always gain more than I lost, tried boot camp private trainer and lost 2 lbs after a year and a half of training. And I am trying not to get the health issues.

I wish you the best of success and hope I can join the losers club soon. Thanks for the response and suggestion.

[mmmorgan 0]

Just found out this morning that I was denied. CRAP! Now I have to wait for the denial letter before I can do anything. This just sucks.

[hope2bthinr 0]

Just found out this morning that I was denied. CRAP! Now I have to wait for the denial letter before I can do anything. This just sucks.

I WHOLEHEARTEDLY CONCUR!! It just guarantees my deductible will reset before I can get the surgery. My Dr was going to do the procedure 9/29 or 9/30 which would have been just under the wire. At this point I don't even care about the deductible, I'd gladly start over and pay the whole thing if they would just give an approval.

I'm still waiting for the surgeon's office to call and find out what went wrong. :blushing:

[mmmorgan 0]

Nevermind! Just found out Tricare approved me after all. They called my drs. office and said that they denied me because they didn't receive all the clinicals in my paperwork. The receptionist said that she then faxed them about 6 times because it wasn't going through. So today I checked the Tricare website and now I'm approved!!! I'm soo excited!

[milwif 0]

Nevermind! Just found out Tricare approved me after all. They called my drs. office and said that they denied me because they didn't receive all the clinicals in my paperwork. The receptionist said that she then faxed them about 6 times because it wasn't going through. So today I checked the Tricare website and now I'm approved!!! I'm soo excited!

Congratulations Morgan!! Isn't it a great feeling? Now you have to start getting nervous again...only this time it's not for your approval, it's for surgery!