Approved!

I just got a call from my case manager at Triwest. I am approved!

Next step is to connect with the surgeon's office, which should be a little easier now that I just need to make an appt for a pre-op, instead of trying to talk specifically to the insurance coordinator. I was told at my initial consult that surgery is usually within two weeks of that, but there have been vacations for the doctor in June, so she may be scheduled farther out.

This has been an emotional roller coaster for me, from the day I first found out that Tricare would cover a Lap Band! Right now, my hands are shaking.
I don't think I have any unrealistic expectations. I'm anxious, and eager to get this taken care of. My sweet husband is supportive, and is already thinking of ways to shop and cook that will accommodate my needs. I admit that I've been enjoying some foods that will be off limits after surgery, but that will stop now, and I will stick with the salads and fresh fruit that are already in the refridgerator.
I've stopped drinking colas...three different times! That one will be hard, but I know I can do it. I stop, and am able to stay away from it for days, then when no progress is made towards approval, I indulge. So, progress is made, and I will stop caffiene!

I guess I'll go check out the ticker site, and finish my personal profile!

CONGRATULATIONS!!!!!
I am so happy for you. I am waiting on the psych to send my eval to the surgeon, then they will submit to Tricare. Hopefully I will join you soon.

Kitty,
have you talked with anyone at Tricare yet? Which region are you in, and which level of Tricare? I was surprised at how quickly it was approved. The doctor's office sent off the needed paperwork today, and because this has been in process for several weeks, I have a caseworker assigned. She called me this afternoon - after the end of her business day - to tell me she had pushed it through the system and everything is a go.
She also asked me to call and update her when I got scheduled!

I am Tricare South, Prime. How do you get a case worker? I just called earlier this evening, just to see what the requirements were (what part of the MetLife scale they go by, high end/low end?) and still got nothing out of them. The lady I spoke with thought I was asking her to tell me if I would be approved. I am over their 100 lbs if my doctor says I am small framed (borderline on that as well), and mid range for the medium frame.I explained this to her and she told me yet again that she couldn't tell me if I would be approved or not. AGAIN, I said I was not asking her if I would be approved, I asked what the requirements were exactly.

Congrats on getting your approval. I've nothing but good things about Triwest approving LB surgery. I'm Triwest too and am just waiting to see the doc so I can get my surgery date for approval. I'm beginning to think he's jerking me around because they aren't wanting to take Tricare anymore but agreed to do so.

I did not get a case worker assigned until the surgeon's office submitted the request for authorization the first time...my husband retired the end of May, and he is working a new job with different insurance, so that created several hoops that had to be jumped through to get this all together.
When the first request was submitted, the other insurance had not sent a denial letter (they cover nothing), and since Tricare is automatically secondary insurance when another is in place, that had to be included, and they don't work as fast as Tricare, so it didn't get submitted again before the end of May, and come June 1st, we were no longer in DEERS! Had to get new ID cards, collect the denial letter and resubmit under Standard.

One of the reasons why they may be giving you the run around for details on requirements is that each procedure can actually have additional CPT codes, depending on what is done, and those will effect the cost. Since most customer reps see this process only from their side of the phone, they can't 'get' why we want/need more information! I spent a lot of time on the phone trying to pin things down, so I know where you are coming from.
So much depends on what your PCM says when he requests approval! Mine wrote a letter to go with the request...outlining the diets I've tried over the last 25 years, and what my co-morbidities were. He was very 'generous' in his descriptions...I cried when I read the letter! But, I think it helped. The first phone call I got from my case worker was to verify the information in that letter...height, weight, medical problems, diets tried. She was very kind as she asked me all of those embarrassing issues...and has been an absolute cheerleader since then! She has called me when she did not need to, just to let me know that she was ready to finish the approval when the paperwork arrived.

(Have I mentioned that I'm Triwest?)

I'm going to have a hard time sleeping tonight!

One of the times I called Tricare I got someone who understood what I was saying, but said she didn't really have an answer for me. The only question I have is how they look at your weight compared to the scale. If the scale says 118-132, and you weigh 225 is that good for the 100 lb over requirement OR would you have to be over 232? That was my only question all 4 times I have called and no one has answered it. I have a few comorbids(arthritis (knees, ankles, hips), high blood pressure, borderline diabetic), that isn't my problem. My problem is the weight, I lost several pounds when my husband was in Iraq and am still in the process of packing it back on since he came home, so I am wondering if I should go back down and reweigh. I think I have put on another few pounds since then. Wonder if they will take my word for it? Doubt it, just thinking out loud. :)

I wish I could give you the definite answer, Kitty, but I'm thinking, with the co-morbidity issues, you should make it! I'll cross fingers and toes for you...

If the amounts that I've heard for what Tricare pays are anywhere near the truth, I can't say as I blame any provider for not wanting to accept it. But, DANG IT! We are in this situation because we have a family member working hard for YOU. Can't you help us out a little in return? He certainly could make more money in the private sector! (And, probably get better insurance coverage, too!)

Congrats, Congrats! I have Tricare Prime (AZ) and awaiting to have a sleep study done on the 27. After that I'll have my psych eval, doc's eval, infertility and sleep study submitted for approval. I'm not over 100lbs so I'm hoping the two co-morb's will help out. I'm getting super anxious! My hubby is active and has two years left for retirement so I'd like to get this done sooner than later. Best of luck to you!

Choromom - Yay!! I am so happy for you. I have my appt on the 25th, so we'll see how it goes...how is the insurance coordinator at Dr. Richards office? Is she the type to work her butt off for you or just submit what she has to? Does she know alot about Tricare?? How did you know what your pcm put in for your referral? My doc on base just typed something into the computer and said "ok, its submitted" I dont think he wrote any kind of letter! You must be so relieved to not have to worry about getting approved anymore...

Thank you for the enthusiasm...it is wonderful to be able to share. Let me answer your questions:
Jill is the insurance coordinator at Dr. Richards office. She knows her stuff. Business-like, hard to connect with on the phone, but they've also had one gal out on maternity leave. I feel like she knows what's going on.
As for knowing what my PCM submitted...I used to work in that office. I just asked one of the gals to fax me a copy of his letter, because I wanted to know what I was dealing with. It is part of my medical records, and I am entitled to a copy!
I am relieved to have the authorization in place. Now, I just wish I could get past the voice mail and talk to a real person when I call the office!

I know, getting a hold of them is next to impossible!! I have had luck getting Tina at the main number usually first thing in the mornings, but I tried calling this morning, and no luck! She did tell me that they were in the process of moving from 2 offices to 1, so sometimes they wouldnt be at the one number....its so frustrating!!

im new to this site but i was wanting to ask you some questions my dr sent my referall to tricare yesterday and i went online and it was approved now i have a dr assigned to the lap band what do i do next

Martinez75,
Congratulations, and how fitting to get your approval in time for the 4th of July...the start of new freedom for you and all of us!
If you have not seen the doctor who is approved for your surgery, the next step is to contact his office and set up your initial visit. That's when you will find out what he/she requires before surgery...could be a gastric scope...easy to do and not a big deal, or a psych eval...also easy. (They just want to make sure you don't expect to wake up from surgery looking like Cindy Crawford!)
Tricare doesn't require a lot of that, but your surgeon might. They will help you coordinate with Tricare for anything that needs to be done.

Good luck, and keep us posted!