Questions about Tricare Approval! Help Please!!

[chatty826 4]

Hi,

I am just starting this process and this forum has been a great help. I have a question about lap band approval. I know I need to get approval from Tricare for the surgery and that my surgeon will submit that information. But I went to my seminar last night and they were setting up consult appointments and I am unsure if I have to get a referal from my PCM for tricare to cover this? If so how long does it normally take? And has anyone paid for this out of pocket? If so how much did it cost you? Thanks so much for any help you can give on the tricare process. I don't think I will have any problems getting approved due to my BMI and hypertension but I am excited to get going.

[Kristine73 1]

Hi,

If you want tricare to pay for the initial consultation w/the surgeon, then yes, you'll need a referral from your PCM. Here is info for you, I suggest you print it out, read it. As you read it, highlight and/or make notes of the info that pertains to you. Also, highlight info that will help your PCM use the right info and language to get the referral. I did this and it really sped up my process. Also, ask your doc to put in some magic words in the reason for the referral request area that tricare likes to see for this type of referral: "to diagnose and treat morbid obisity."

The links:

tricare manual

http://manuals.tricare.osd.mil/index.cfm?fuseaction=TMAManuals.PVCSGetFile&PluginVersion=5&ReferenceManual=TP02&ReferenceChange=66&Type=ASOF&Manual=TP02&FileName=C4S13_2.PDF

metlife chart

Met life ideal height weight tables references

Good luck

[RestlessMonkey 7]

Depends on what type of tricare you have, actually. I have Tricare Standard and did NOT need a PCP/PCM referral. I did, however, have to choose a surgeon working out of a "Center of Excellence". They have a staff member there who filed all the paperwork and I was approved in 2 days. You may want to call tricare and find out what requirements apply to you with your coverage.

[chatty826 4]

I spoke with my PCM's referal coordinator today and she said that tricare doesn't require them to put in the codes and stuff for the consult. I will call tricare today to confirm.

[chatty826 4]

Also has anyone been denied a referral if their PCM requested it? BTW I have Tricare Prime in the West Region.

[talkalot1981 5]

I have Triwest also. I had to go to my PCM. I told him I wanted to see about getting the lapband. He put in a referrel to Triwest. 2 days later it was approved. I checked online and found out I was approved. Tricare chose which surgeon I got to see. Tricare faxes that surgeon my approval and I called them and made an appointment. After I got all my pre-op testing done, the surgeons office, send in my paperwork and I waited for Tricare to approve the surgery or not. 4 days later I was approved. My PCM didn't have a problem with sending in a referrel to tricare, I was oviously overweight enough to get the surgery. I hope this helped but I am not sure if it make sense.... Jennifer

[chatty826 4]

I have Triwest also. I had to go to my PCM. I told him I wanted to see about getting the lapband. He put in a referrel to Triwest. 2 days later it was approved. I checked online and found out I was approved. Tricare chose which surgeon I got to see. Tricare faxes that surgeon my approval and I called them and made an appointment. After I got all my pre-op testing done, the surgeons office, send in my paperwork and I waited for Tricare to approve the surgery or not. 4 days later I was approved. My PCM didn't have a problem with sending in a referrel to tricare, I was oviously overweight enough to get the surgery. I hope this helped but I am not sure if it make sense.... Jennifer

Made lots of sense thanks! Is your surgery being done by a civilian doctor? I alreay have a surgeon lined up and Ive checked around and think they are the only one in my area that accepts tricare.

[Tina254 0]

I have some questions...

How do you calculate the 200% or more over ideal weight? (sorry might be stupid question but I really don't understand it)

I am 275 lbs. 5'5. with a BMI of 44. Medium frame.

According to the Met life chart I'm supposed to be 127-141 lbs for my height weight. Am I 200% or more over my ideal weight?

The reason why I'm asking this is because I'm not sure if I qualify for the 100lbs over with co-morbities so I'm counting on being in the 200% or over range. I know I am over 100lbs but I don't have strong co-morbid because first of all I haven't been tested for all of them and second the ones I have been tested for are not strong enough. I have pre-diabetes, lower back pain, and secondary amenorrhea but I don't think tricare will accept those.

Thanks!!

[Kristine73 1]

How do you calculate the 200% or more over ideal weight? (sorry might be stupid question but I really don't understand it)

It's not a stupid question. Unfortunately, I couldn't begin to tell you how they figure it. Your PCM may be able to figure that out for you.

As RestlessMonkey stated, a lot depends on what form of Tricare you have, Standard, Prime, etc. Also, the region you are in can make a difference.

I have Tricare Prime and live in the South. I was worried my co-morbidities wouldn't be considered strong enough by Tricare. I have high blood pressure and my cholesterol is 201. My doctor considers 199 borderline high. I had my gallbladder removed a couple of yeas ago. My doctor told me that once that's removed, they consider any gallbladder issues "cured." So, I was worried. But, the referral to see the surgeon was approved the SAME day. I couldn't believe it.

The patient advocate at the surgeons office told me that Tricare is one of the easiest to deal with, as they are straight forward in their requirements and don't play a lot of games like some other ins co's. The patient advocate also told me that Tricare doesn't require as mush pre-op crap as some other ins co's. I had to do a psych eval and have my PCM decale me healthy enough for surgery. They ordered some blood work and did and EKG. That was all. I was approved.

The patiend advocate told me that the people in the surgeons office know how to word and code things for each ins co. One thing I'd recomend though, if you need a referral to see the surgeon, is have your PCM say that the reason for referral is "to evaluate (or diagnose) and treatment of morbid obisity." Someone on this board gave me that nugget of advice when I first started out, and I think it helped push the referral through.

Good Luck

[Tina254 0]

As RestlessMonkey stated, a lot depends on what form of Tricare you have, Standard, Prime, etc. Also, the region you are in can make a difference.

I have Triwest with tricare prime. I am just hoping after my first initial visit I get approved for the surgery!

[katwmn63 0]

I had this same question so i called tricare for clarification:

254-282 is the range you need to fall in to qualify as 200% or more for your height, med frame (basicaly over 254). So yes. If you are twice as much as your ideal weight...you ae 200% or more.

hope this helps:)

[Lilpeach_059 0]

I had this same question so i called tricare for clarification:

254-282 is the range you need to fall in to qualify as 200% or more for your height, med frame (basicaly over 254). So yes. If you are twice as much as your ideal weight...you ae 200% or more.

hope this helps:)

Which Tricare do you have? I have Tricare South and they would not tell me my ideal weight! Most of the reps (that I spoke to; about 7 or 8) even said they dont use the metlife chart!

So how did you approach/word the question?