Federal Blue Cross/blue Shield

GIGGLEADP · 03-06-2007, 09:26 AM

Hey has anyone been able to get prior auth form Federal BC/BS? My doctor will not do the surgery without prior auth. Can anyone recomend a surgeon in Arkansas that will do the surgery without prior auth?

dotofoz · 03-06-2007, 09:51 AM

I have FEB BLUE HMO Ohio and had no problem getting approval. My friend has the PPO and had no problem w/approval. My suggestion is to give them everything they want, and more. Your DR office will help you w/what is required of specific plans.....Good Luck!

DrHekier · 03-06-2007, 06:16 PM

There may be different 'flavors' of Fed BCBS, with some PPOs providing preauthorization.

We have been told by our Fed BCBS representative that they do not provide pre-authorizations or pre-determinations. They say if you meet criteria they will pay for it so they are asking us to take it on faith.

We are waiting to get reimbursed on our first Federal Blue Cross Blue Shield patient done in 2007. If we see there are no problems with reimbursement than we will do them more frequently. I read here on this board of another patient with Federal Blue Cross Blue Shield who paid the surgeon and hospital and then filed on the insurance to get the reimbursement.

soulful Grandma · 03-16-2007, 11:42 AM

My DH and I just had some very interesting conversations with Federal BCBS (Rhode Island). I am pre-op, will get my surgery date April 12. I've had all my pre-op testing, so far no problem with payment on those.

I was concerned and wanted to talk to them myself prior to the surgeons office seeking approval. Boy, did I get a runaround! First rep I spoke to said I had to get a CPT code in order for any questions to be answered. That seemed odd, to ask the patient for the CPT code, so I called back and got another rep. She told me lap band is "experimental and not covered". I asked her what was experimental about a procedure being performed for 15 years and covered by many other insurance policies. Then she told me oh, then get a code!

My husband called them and read them the riot act. They told him to call back with a code. (at least they are consistent) Then he called the surgeons office (they were amazed that anyone would ask the patient for a code, and they do the majority of the surgeries in this area, Preferred provider, and operates at a Center of Excellence!) He got a code, called and they denied it. Called back with 2 more codes, both are covered, but boy were they ever reluctant to admit it. the codes they say are covered: 43770 and 43843, in case that helps anyone. It's my understanding that 43770 is the standard CPT code for Lap Band, but I'm not an expert by any means. So, I'll let my surgeon know, and I'm hopeful for the approval - but they'll find a way around it if they can. Sorry if I sound cynical, but I've had so many insurance experiences where they just try to get you to give up - if they make it hard you may give up and save them the $$.

I'll come back on the thread if/when I get the approval....... I have co-morbidities and BMI of 47, so I believe I meet the quals!

flowergurl · 03-21-2007, 01:33 AM

Interested to hear if you've gotten through BCBS yet. I just attended lap band seminar tonight for Little Rock Dr. Wellborn and they refuse to accept BC/BS Federal plan b/c they will not offer pre-auth or pre-approvals. They suggest I pay out of pocket then get reim later. I cannot afford to do that or risk going into further debt. I'm considering traveling to get banded. BMI 46 with no co-morbidities and no wls exclusion in medical plan.

dotofoz · 03-21-2007, 11:47 AM

I have also checked and if you insure federal employees (ALL fehb carriers) MUST cover WLS. They each have their own criteria, like they can make you jump thru hoops, but it is federal law that they must cover it! You can google "fehb morbid obesity", that may help. I'd also check your plan brochure on line, check out www.opm.gov. It also helps if your surgeon/facility is on their prefered provider list, like mine was. Don't let them jerk you around, you're entitled to the procedure, go for it! Good Luck!

soulful Grandma · 03-21-2007, 04:30 PM

thanks for the info dotofoz! I'll not give up without a fight, and I intend to win.
Flowergurl, I go back to the surgeon 4/12 and as soon as I know anything, I'll update here.

soulful Grandma · 04-13-2007, 03:41 PM

Well, dotofoz was right. I have my approval, the surgeons office obtained it no problem. They also gave me my surgery date, May 14.

flowergurl · 04-13-2007, 03:48 PM

Congratulations! Thanks for coming back & updating.
Do you know if BCBS actually gave an approval number?
I've been sitting on it & haven't made anymore phone calls or even gone back to my referring physician yet.

soulful Grandma · 04-14-2007, 08:31 AM

Thanks, Flowergurl. Approval number - yes Fed BCBS did give them an approval code. I have Non-federal BC Healthmate secondary coverage, and they stated to my surgeons office that they would pick up any copays and uncovered items without an authorization, not required for secondary.

Good Luck and Don't give up!!!! remember what dotofoz said.

soulful Grandma · 05-07-2007, 10:32 PM

Flowergurl,

Been thinking of you - how's this going. Any progress? don't get discouraged!

ouachita · 05-08-2007, 09:13 AM

Congratulations SG and good luck Flowergurl!

dotofoz · 05-08-2007, 09:13 AM

What does your brochure say?

flowergurl · 05-10-2007, 09:29 PM

soulful Grandma: Thanks for thinking of me! Actually, I'm still sitting here & have done nothing. I haven't called BC/BS back yet nor have I contacted other surgeons in my area. Since tomorrow is Friday, I will make it a resolution to get make progress starting Monday before the holiday. You are almost there--just a few days! I wish you well & anxious to hear from you when you're feeling up to it.
ouachita: Thanks for the luck--hopefully I can find out something positive soon!