BC/BS wont tell me conditions of coverage

Lisa*in*NJ · July 8, 2005

What to do????? I want to make an appointment with the surgeon for a consult which is out of pocket..$85.00-ok I can handle that. The problem is, my insurance co- Horizon Blue Cross Blue Sheild will not tell me what is required to be approved. Without their coverage I can not have this done. I hate to waste the time and money if I don't qualify to begin with. Don't I have the right to know ahead of time if I have a chance of being covered? Anyone else run into this problem??

Marimaru · July 8, 2005

Do they have a website that you can login to? I have BC/BS in California, and they have a website and I was able to look it up. If not, I'd call and ask, and each person that told you no, I'd ask for their superior. I think you most definitely have a right to know before it's submitted.

Alexandra · July 8, 2005

Lisa, I can ASSURE you that BCBS of NJ looks very kindly on WLS, including banding. If your surgeon has dealt with them before, he should be able to give you a very good idea of what's going to be involved in getting approved.

NO carrier will ever guarantee that something will be covered before the fact. It all depends on the information they receive at the time of the claim. The medical case for bariatric surgery is clear: a BMI of 40 or above, or of 35-39 with two co-morbidities. If you meet that medical definition (and presumably you do, or your surgeon wouldn't be considering you as a patient) Horizon DOES cover bariatric surgery.

Horizon doesn't have any fancy qualifying regimens or pre-op hoops you have to jump through. They say if it's medically necessary, it will be covered in accordance with your contract. So all you and your doctor have to show is that it's medically necessary.

Alexra · July 8, 2005

I have BC/BS NJ PLUS which is the state employee plan, if any plan would deny it I would think the government one would and they approved me with NO problems. In fact it only took about 1 week to get approval. I had a BMI of 51 at surgery time and had no co-morbidities.

Plus I didn't have any out of pocket other than a $10 co-pay. If you have a referral from your Primary Care Doctor the consultation I would think should be covered as well.

Good luck

Lu Ann · July 8, 2005

We have Anthem BC/BS here at work, and my friend just got approved because her BMI was at least 40. She had no other problems.

However, I have to be a self-pay because mine was not 40, ;-( Close, but no cigar!

I feel like it would be worth your $85.00 to go and find out. Chances are good you will be approved.

Alexandra · July 8, 2005

Lisa, why is the surgeon's consultation fee out of pocket? Is the surgeon in your network? If the office visit isn't covered with a copay I'd be concerned that there will be some issue with how the surgery will be covered. What kind of plan do you have, and are you sure the surgeon participates? And the hospital?

Lisa*in*NJ · July 8, 2005

thanks everyone for the responses. I did call back and spoke to the 3rd person, she was a lot more open with me and was a geat help.

Alex~

I was told by the surgeons office that they did accept my insurance but would have to pay the consult up front...hmm, for whatever reason. What I failed to realize was that my insurance Horizon BCBS-(POS) will only let me go to a surgeon in my network-in NJ. I may sound clueless but I really never needed to know any of this before. So back to square one. I wish I were closer North so I could go to your Dr. but at this time I just can't travel that far - 2 1/2 hrs. I guess I really shouldn't complain because look at all of the people who have to travel to Mexico. So now I am on the hunt for a surgeon a little closer to home - At the very least, want to get a consult set. I visited my PCP on Tuesday and he said once I find one, he will give me a referell(sp?) asap.

Thanks again for your help, any other suggestions- I am all ears!

Lisa

Alexandra · July 9, 2005

Hey, don't apologize for not knowing all the ins and outs of your insurance policy. MOST of us don't read that stuff until we need it.

As far as the doctor telling you they "accept" your insurance but you have to pay up front, that means they're not in your network. Saying they "accept" a plan is not the same thing as saying they're actually in the network. And this is a VERY important distinction, when it comes to big-ticket procedures like surgery. Be sure you find a surgeon who is a participating physician with the Horizon POS network, and you won't be socked with a big deductible and coinsurance payment.

I know there are banding docs in South Jersey, aren't there? If you have trouble finding one, though, 2.5 hours might start looking like less and less distance to travel.