Question:
Is Precertification the same as approval?

I am so worried. I've waited forever and it seems I'm getting no where. All my paperwork has been submitted to BC/BS for precertification and they still have not received it but said it takes 2-4 wks to even get in their system. My question is...Is preceritification the same as gettign approved or will I have to wait another month or two on top of this? I sure could use your help guys...especially if you have traditional BC/BS of MI. Thanks a bunch and have an awesome weekend!!!!! Josii*    — meltedbuttr (posted on January 10, 2003)

January 10, 2003
Hi, Josii.... not sure how much this will help, but.... I was told that 90% of the cases that get precertification approval will also get absolute approval. I have United HealthCare, and my Doctors got pre-certification approval instantly over the phone, that is just a preliminary to rule out any exclusions in your policy. Once that was done, the insurance wanted a "Letter of Medical Necessity", which my doctors said gives them an opportunity to run tests and qualify patients for surgery based on medical need. Once they submit to insurance that the patient's request for surgery is medically necessary, then insurance has Nurses and Doctors who review tests results, they also check with employers (if applicable) for final approval. If your doctors are thorough in their testing, and you meet the standard qualifications for surgery, and if you work for a large employer your chances for approval are great. The larger your employer the better. Hope this is helpful. Good luck.
   — Gina C.

January 10, 2003
Preauthorization is a review of medical records to determine if a procedure or test is "medically necessary" acording to your plan guidelines. Yes, sometimes this may take a while, some are lucky and it is no time at all.<p>Precertification is a simple phone call, usually done by the DR. Insurance companys can reduce your benefits if precertifications isnt done. There are about 10 simple questions. There should be a phone number on your ID card that says "To precertify call ##########).<p>Hope this helps. Mary
   — Merry I.

January 10, 2003
Yes, it should be the same thing, but precert is telephone and the doctor will need written approval. Hang in there, everything should be fine!
   — shanmarie M.

January 10, 2003
I believe it is submitting for an approval. I have BCBS United of WI and my approval was submitted for pre-authorization which ended up providing a written approval letter. I think it's just a variation of terms. Normally pre-certification would be something a doctor's office would get by phone like for admission to a hospital. Since weight loss related services is usually excluded, except in the case of morbid obesity and disease etiology (at least in the case of my policy) the detailed review process allows them to decide ahead of time that the surgery is medically necessary and not finding out after the fact and having them refuse to pay. For instance my surgeon did pre-certification for when I had my galbladder removed years ago but did not submit for pre-authorization as there is no exclusion for galbladder removal.<p>I don't know about your BCBS but mine has a tendency to lose things 2 to 3 times before they are able to hang onto it. If it's possible to take a full set of the stuff the surgeon sent to a regional service center and get it signed for you would at least have proof that it got there. As far as 2-4 weeks that's insane. If you have a letter of medical necessity, detailed diet history including lbs lost, supporting documentation from other providers of co-morbs and a psych eval done specifically for the WLS then they should be able to turn it around in a week to two. My approval took 2 weeks but it occurred over the Christmas/New Year's weeks and they were closed 4 of the 10 days. My approval was also slowed by a mailed letter requesting the detailed diet history, which my surgeon did not include even though he had it. So 1 week to either get an approval or a request for additional information should be adequate. I'd be bugging them and asking why it should take so long.<p>One last thing. I hope you plan to have RNY or Vertical Banded Gastoplasty. They do not cover DS or any other procedures. Just wanted to forewarn you so you don't get surprised at the last minute. From what I can tell this seems to apply to all BCBS companies nationwide. Good Luck!
   — zoedogcbr

January 10, 2003
Hi, I have BCBS of AL. It took awhile for them to get everything they were looking for into their system, They made a few requests for more information, MY PCP had never done this before so she wasnt prepared. Once they got all they were looking for they were just waiting to hear from te surgeon what procedure he was doind, the insurance co actually called my surgeon to find out, I was approved in 1.5 hours (if that long) So once they actually get the stuff they want into their system it doesnt take that long. GOOD LUCK
   — nicole79

January 11, 2003

   — Merry I.

January 11, 2003
If your doctor's office submitted the information, they may have sent it directly to the office doing pre-certification. If this happens, the application does not go through the usual channels-- i.e., first to an intake person who enters it to the system and then, eventually, to the pre-cert office. If it goes straight to pre-cert, then it doesn't get entered on the system until the case officer actually gets to your file-- and your answer is a few days away. This happened to me, and I discuss it on my profile and under my discussion of my insurerer. Incidently, my insurerer is Carefirst BC/BS, a combination PPO/traditional insurance. <br> Good luck! Beth
   — Beth S.

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