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DENIED - Federal BCBS

vhowley

By vhowley, in Insurance & Financing

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Acceber12    5

Acceber12
Posted

That does seem odd. The plan's terms and conditions should be available to you in writing. If your insurance policy is through work, and the benefits person at your work won't give you the Plan Document after you make a request (even better if you request it in writing), you can call the DOL and they can help. Employer sponsored health insurance is covered by ERISA. Good luck!

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KristenLe    5,979

KristenLe
Posted

Thanks. I can see that it's covered but can't get the info about what requirements I have. BCBS told me I had to do a 6 month supervised diet but when my surgeon's office checked they said I don't. I'm just concerned not having anything in writing and something is going to go wrong.

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vhowley    7

vhowley
Posted

Welllllll....I submitted all my paperwork on the 10th of May...and went ahead with the surgery on 5/17 as "cash pay"...because I had already taken soooo much time off from work in preparation for the surgery and other medical appts.

I received this letter from the Reconsideration department...which frustrates me...because they are looking for program participation between May '15 - present. My main argument for the reconsideration IS the lack of definition for "prior to surgery" verbiage.

post-291665-14639558176082_thumb.jpg

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UsernameTaken    283

UsernameTaken
Posted (edited)

Hi, looks like your insurance is BCBS IL Federal, (mine is basic) is that correct?

I have the same insurance and yes they do require 3 mon diet before the surgery. I had to do it.

post-269102-1463956527575_thumb.jpg

See the pic (from their benefits brochure online) this was from Jan 1 2016. Is it possible you make have a looked at the requirements of different BCBS of Il?

Edited by UsernameTaken

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UsernameTaken    283

UsernameTaken
Posted

I just have BCBS Federal (FEP). If you look at my earlier posts I have contested the wording in paragraph for medically supervised program...

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True but it still says 3 months prior to surgery date right?

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vhowley    7

vhowley
Posted

The BCBS FEP advocate agreed that the verbiage leaves room for interpretation.

You read it as "3 months JUST prior to surgery"....I read it as 3 consecutive months prior (read BEFORE) surgery.

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