Pre-determination vs. Authorization?

[TXAmy07 0]

So my surgeon's coordinator submitted my paperwork to Cigna for approval last Monday, and I called them this morning just to see if they had received the paperwork.

I told the girl that I was calling to see if they had received the paperwork for approval, and she said that they had received it NOT for approval but for pre-authorization. She went on to explain that pre-authorization was just to find out if it was a benefit that was offered and paid for by insurance, and that authorization is when the doctor calls in for an authorization number and then sends in the Cigna-required documentation (6 month supervised diet, psych eval, etc etc). She said these are two different departments that handle this, and the way the paperwork was sent in was for pre-authorization and NOT APPROVAL and the approval department would not see this paperwork.

She said that it would take 15 days to get a pre-authorization since that's what was sent in for (not that I need one, we already know it's covered and the requirements), and they would have to re-submit paperwork to the authorization department for the approval and that takes 15 days.

I called my surgeon's insurance coordinator (who is not the most friendly person ever...) and she said "pre-authorization, approval, it's all the same thing" and I explained to her that I just spoke with Cigna and what they told me about it being two different departments. She said (totally rudely) "well, I work with Cigna every day and I ALWAYS send this paperwork into the same department and it is always just fine, so you just need to wait a week or so and then try them again". Then she practically hung up. :frown:

So. I'm not sure who to believe - her or Cigna? On one hand I want to believe that she knows her job, but she is not the same coordinator I began this process with, that one got promoted and this one is sort of new I guess and when I first called and spoke with her she said that I needed 5 years of medical records and I told her I only needed 2... She went and checked and said "oh yeah you're right, it's just 2"... I guess that is making me doubt her somewhat.

Has anyone else had this issue, or does anyone know anything at all about it? I hate being this close and having things start to mess up!

Thanks in advance for any help at all!

[Jodi_620 37]

Before you move forward, be sure to do two things.

1.) Talk to your surgeon and discuss the poor treatment received by the insurance coordinator. This surgeon is being paid a lot of money to provide all aspects of the Lap Band to you, including insurance coordination. The staff was a big part of deciding which surgeon I would go with.

2.) Make sure you get approval in writing before scheduling surgery. If I were you, I would call my insurance company back and confirm what you have been told. Then explain to the insurance rep what is going on. Maybe they will call the coordinator and work to get it straightened out.

[TXAmy07 0]

Jodi, thank you so much for the advice.

I took that advice and called Cigna again and got a super helpful lady that explained to me that the first person I spoke with this morning was actually completely wrong. She said exactly what the insurance coordinator said - pre-authorization and approval is the same thing for them, and my paperwork was in the system to be pulled for Nurse's review. She was able to access the system and "pull" the paperwork for review which I guess puts it into the nurse's queue, and they will review it to approve it and give it a "pre-authorization code" and send a letter to both the surgeon and me stating I am approved. (or that I am lacking whatever)

She also looked at the paperwork and said that it looks good and thorough.

So I might owe the insurance coordinator an apology, especially if she thought I was trying to say she didn't do her job correctly but whatever. There's no reason to be rude about it! I did pick them because their coordinator (at the time) was so helpful and she'd been through the surgery and let everyone feel of her port at the seminar and she just overall rocked... Now, not so much!

Anyways, thanks for the input. I needed that!

-Amy

[ahb08 0]

Jodi, thank you so much for the advice.

I took that advice and called Cigna again and got a super helpful lady that explained to me that the first person I spoke with this morning was actually completely wrong. She said exactly what the insurance coordinator said - pre-authorization and approval is the same thing for them, and my paperwork was in the system to be pulled for Nurse's review. She was able to access the system and "pull" the paperwork for review which I guess puts it into the nurse's queue, and they will review it to approve it and give it a "pre-authorization code" and send a letter to both the surgeon and me stating I am approved. (or that I am lacking whatever)

She also looked at the paperwork and said that it looks good and thorough.

So I might owe the insurance coordinator an apology, especially if she thought I was trying to say she didn't do her job correctly but whatever. There's no reason to be rude about it! I did pick them because their coordinator (at the time) was so helpful and she'd been through the surgery and let everyone feel of her port at the seminar and she just overall rocked... Now, not so much!

Anyways, thanks for the input. I needed that!

-Amy

amy who is the company ur working with??? im with lapband solutions/true results..they offices in hurst and n. dallas....i was just wondering if we were dealing with the same people so i can be prepared for these same issues!!

[TXAmy07 0]

Well, it turned out that the problem was the idiot that answered the phone at my insurance company (Cigna) and not at all the coordinator. :smile:

I am going through Lap Band Dallas, and they got me a pretty speedy approval.

Good luck on your process!

[ahb08 0]

Well, it turned out that the problem was the idiot that answered the phone at my insurance company (Cigna) and not at all the coordinator. :smile:

I am going through Lap Band Dallas, and they got me a pretty speedy approval.

Good luck on your process!

thanks amy good luck to u too girl!! hopefully around the time of ur surgery ill be getting approved for it...