APPROVED - Anthem Blue Cross Blue Shield

Ellisa · 11-19-2007, 07:31 AM

Who knows. I have Anthem BC/BS of Ohio. Mine was sent in 6 weeks ago. For 4 weeks they claimed they didn't have anything. But the doc's office had a confirmation that they did. Then I got a "pended" letter which from the looks of what they were requesting someone must have lost half of my paperwork. That was faxed again last week, and now I'm still getting that nothing has been received. I can't get past customer service. Every time I'm transferred all I get is a voicemail and on one ever return my calls. Even the doc's office is getting the same "loop."

Some people seem to get approvals within 2 weeks. My experience with othe claims has been hastle after hastle. Surely it's just a coincidence, but it's been very frustrating.

From what I can gather, there is a national BC/BS office that handles pre determinations. I don't think the state or "brand" makes that much difference, but your individual policy does. But then, I could be wrong. It certainly is shrouded in mystery.

Ellisa · 11-20-2007, 12:05 PM

Approved today!

They had misplaced part of my paperwork, but it was found, along with several other copies that had been mailed and faxed.

Approved today.... oh my oh my. I can't hardly think!

Dustout and others, thanks for your support!

dustout · 11-20-2007, 12:58 PM

Congratulations!!!!!!!!!!!!!!!! I'm so happy for you!! Keep us posted on your progress on getting banded and good luck to you on all of it! It sure is 'shady' how our insurance misplaces paperwork and faxes then mysteriously finds them when we bug them ;) but at least we got it! Yay!

I look forward to hearing more about your progress. I'm still loving the band even though I haven't had a fill and can eat more than 4 ounces. I'm still losing about 2 pounds a week though WITHOUT a fill! I eat so much less now than before surgery still. With a fill I'm sure it will be amazing.

Ellisa · 11-20-2007, 02:33 PM

Yes you will do amazing, but don't expect more than 2 to 3 lbs per week. It really does add up fast. My husband did very well before his fills too, but by the time he had his first fill, he was beginning to gain. There was a problem with the facility losing the doc he had and having to wait on someone to be trained. But once he got a fill he began losing again.

But thank you so much, you were right all along!

4jin · 11-21-2007, 01:01 PM

Congrats Ellisa!
I have BCBS of Georgia....I am still in the first section of the beg of the battle.
I have my 1st surgeon consult next week and the following week the psych eval and the mandatory support group meeting. I can't wait to get this submitted!
I called BCBS of GA today and the representative I spoke with was excellent...so great she told me she even had RNY herself and lost 215 lbs! She gave me lots of information on how to attempt for a first time approval with BCBS.

Ellisa · 11-21-2007, 01:52 PM

Wow you do have a great insurance rep! Most people are getting their approvals within a couple of weeks from the time their paperwork is turned in. I had a snag with "separated" paperwork. But it's over now. The waiting for approval has to be the worst.

I have Dr. Curry in Cincinnati area. He has a wonderful person (Tracy) who handles insurance claims. She's on top of what is required and makes sure ever everything is in order. The paperwork issue wasn't her fault. She also was there every step of the way reassuring me that it was going to be approved.

Hope it all goes well for you!

Talyn · 11-21-2007, 10:46 PM

I am a claims RN who works for Anthem. Just wanted to give everyone a heads up about a couple of things: Anthem does not determine whether or not they will pay for the surgery. It depends on whether or not your employer or your spouses employer purchased the weight loss surgery rider. Although you are correct in that there iare general medical necessity guidelines that Anthem follows concerning bariatric surgery ,first your policy must have the rider. If you or your spouses company did not purchase the rider, then you will receive a contractual denial since it's not a benefit that you have

:ranger: Talyn

Ellisa · 11-22-2007, 04:41 AM

Right on! The first step that I took was to make sure there were no exclusions on my policy and which bariatric procedures could be considered.

The customer service reps were extremely nice. Each week when I'd call, I'd think that I was going to get tough because I couldn't seem to get anything but the voicemail loop and no one was returning my calls. But the reps were so nice and professional that I'd let them put me right back in that loop. LOL The issue was that my paperwork had been faxed and a confirmation received, but the data base wasn't updated for a month. Then I received a letter requesting information that had already been sent. The last time I called the customer service rep decided I needed to talk to a nurse. Now we all know, you don't become a nurse unless you are a really caring and thorough person. And that's exactly the kind of nurse who returned my call within the hours and got to the bottom of things. She called me again the next day to tell me I was approved. She didn't want me to have to wait on the letter. Now how nice was that?

The funny part was, when I took the call I happened to be uploading software for another employee. So while my insides were jumping up and down and screaming with joy, my outside person was calm and polite. I hope that wasn't too much of an anticlimax for this very special and caring nurse. LOL She even explained that somehow my paperwork had gotten separated and that I shouldn't have received the "pended" letter.

I don't know about the rest of you, but for me when someone admits mistakes were made and apologizes and remedies the situation my respect for that person and organization soars. I'm not saying that they should approve a case that's clearly not within the guidelines, but checking into it and making sure that it is considered is awesome.

4jin · 11-23-2007, 12:10 AM

Ellisa it couldn't be said any better about the feelings when a person apologizes.
I too called the insurance to make sure LAP-BAND® was a covered procedure in my employer insurance policy. It turns out it is.
The customer service rep gave me the additional specified requirements/criteria they use in order for it to be covered under my employer's policy.
They cover 100% copays are $15 and deductible is $300..

Ellisa · 11-23-2007, 11:24 AM

4jin,

Your policy is excellent! We have a higher "out of pocket," I think $1500 per year. And I'll have to pay 10% of the procedure, up to that amount. I was disappointed to find out that what I consider out of pocket and what Anthem considers out of pocket are two different things. To me it was all medical expenses I've paid to date, which is several hundred dollars. I thought that co-pays and other expenses that I've paid from my flex spending account would be counted. But the allowed amounts they counted toward "out of pocket" I've paid comes to under $3 this year. Yes I said under 3 dollars!

Oh well, it could be a whole lot worse. It'll be worth it.

Stay in touch,

4jin · 11-23-2007, 06:29 PM

Thanks Ellisa,
I was very surprised to hear the 100%....I was so excited...I couldn't even think for a moment....I always sorta thought my coverage wasn't worth what I paid...but they sure just proved me wrong...

I'm sorry to hear about the copays and deductible....sorry to all self-pays...but anything less than self-pay is worth it to me!

destiny79 · 11-23-2007, 07:36 PM

I have UHC Choice plus Texas it pays 90%I have to pay 10% whick came out to be 1400.00 because of my out of pocket max is 1400.00 but I called the hospital that I will be having the surgery they said I could pay some thing every month til its paid off just have to bring 100.00 the day of the surgery . but I had to pay the Dr. up front 300.00 deducatable and fees which came out to be 420.00 so still not bad compare to what I am getting back (my life)

RinR · 11-23-2007, 08:17 PM

I also have Anthem Blue Cross Blue Shield PPO, Federal program. I had checked into everything prior to my surgery. I just recieved a bill from the Hospotal for $6,000. I called the hospital and explained everything. they insist I owe this amount. I called my insurance company and they said that out of the 6,000. I really only owe $1, 200. I asked what is this for and they said that I am only covered for 30 percent of the "medical equipment" charge on the total bill. This was a complete surprise to me.

Ellisa · 11-24-2007, 06:26 AM

I'm not complaining, just explaining. :) I totally agree that $1500 is not bad. Being self pay simply would not be an option at this point.

I haven't been told yet how much has to be paid when. I've already paid a $300 program fee. I doubt that counts toward anything. That's just for the office to process your paperwork with the insurance company. The woman who does it is absolutley wonderful and I certainly got my money's worth. She not only makes sure that you have everything you need and tells you up front if she thinks it will be approved or not. She told me mine was good and I should have no problem. But then I got that "pended" letter and became discouraged. She was still confident that it would be approved. As you can read in my above posts, she was right. If I'd send her an email on a weekend or evening, and certainly did not expect a response until she was at work, she would usually answer within the hour. So even though I expect that money won't count, it was money well spent.

Four years ago I had Med Mutual, I was kind of on my own trying to get everything together. I was denied, within days of my father being diagnosed with cancer and he died within the year. At the time open RNY was considered the safest WLS. I'm glad I didn't have the RNY. I really wish I didn't need to have surgery at all. What I wouldn't give to do this on my own. But if surgery is the way for me, I'm glad it's going to be LAP-BAND®.

The doctor I was with the first time was not in network and I would have had about $5000 to pay out of pocket, so this is much better.

Angelsma · 11-24-2007, 07:06 PM

CONGRATULATIONS! And yes, it helps me a great deal. I have the same insurer.

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