Question:
Is no pre-determination needed a good thing?

I was told by my insurance company that since I have a PPO policy that a predetermination was not needed as long as the procedure is not a policy exclusion, and it's not. Is this a good thing?    — Vida W. (posted on July 2, 2003)

July 2, 2003
With this surgery being so controversial, insurance don't like to pay for it, the cost involved etc. I would get a predetermination and ask for it in writing, that way they can't come back and say anything different. Also, insruance companies have different terminology for different things. Prior Authorization and Predetermination are inter changable words but can mean different things as well. So make sure your asking the right questions, this is one area customer service representatives when you call your 800 # on the back of your ID card get you and don't tell you everything only what your asking. So predetermination may not be necessary, but prior- authorization or authorization is diffently one you want in writing. Confused any more than what you were before you ask???? I've worked in insurance for 20 years and the insurance companies will work it to there advantage. Good Luck.
   — Jeana S.

July 2, 2003
If I understand this correctly, it means you do not need a letter of medical necessity, tests etc. Sounds like you would be covered as long as it is not excluded.
   — snicklefritz

July 2, 2003
I was told the same thing by BCBS. They sent me a letter letting me know what the doctor needed to do when sending in the claim. When the doctor's office sent in for pre-approval they got the same letter stating that the surgery would be covered if medical necessity was proven. When the insurance coordinator called the insurance company they told her to be sure and include every weight related medical problem and diet attempt for the past 5 years and there should be no problem with the claim.
   — plucmn

July 2, 2003
I have the same thing with my insurance, but the surgeon will still require them to approve it in advance.
   — Saxbyd

July 2, 2003
I think in my case it's a bad thing. I have BCBS of MI PPO, and they don't req any PRE anything. I had to pay about 15,000.00 up front for my WLS. I hope once the paperwork is sent to ins that they will cover my surgery and send me a check!! (I'm not holding my breath) Good luck!
   — luckyflowers

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