Question:
I received a letter from my insurance company on Sat. and am not sure if approved!
I got a letter that says this: This letter is in response to your recent inquiry for predetermination of benefits for the above patient. Based on a thorough review of the medical documentation submitted, the Roux-En-Y Gastric Bypass, has been determined eligible under your current health plan. (it then goes on to discuss payment information about non-participating and participating providers) Please be aware that this is not a guarantee of payment. Upon receipt of the claim and any supporting medical documentation (i.e. operative report, physician's notes), final determination of eligibility, allowances, and disposition wil be completed. So, what do you all think this means? — Erica C. (posted on August 25, 2002)
August 25, 2002
they are telling you that you are covered for weightloss surgery but you
must go thru the hoops i.e. see your primary doc for a referral to a
surgeon, contact the surgeons office and go thru the hoops they want you to
do such as attend an info meeting,etc. good luck
— Jena C.
August 25, 2002
Yep, it indeed means you are elegible for the hoop jumping. With the proper
documentation you are there!
— Sue A.
August 25, 2002
I take it as you have not sent in any of your paperwork- you were just
checking to see if WLS is covered? If this is the case, they are telling
you that they DO indeed cover it as long as you send them the appropriate
paperwork, such as surgeon info. My insurance company
<i>only</i> required paperwork from my surgeon. Your's may
require more info such as from your PCP, a list of failed diet attempts
(either doctor-supervised or not), and possibly various other
documentations. You should call them and ask exactly what they need and go
from there. It's great news though! At least you know you have a real
chance!!! Best of luck!
— karmiausnic
August 25, 2002
I assume you must have submitted some kind of medical info to the Ins CO.,
since they state ,as a result of their review of it,the proc is considered
eligible.I work for BC BS and when they send a letter like this, then go
ahead and quote your Benefits, it means it is approved. The other comments
only mean that when the bill finally comes in they will make sure you are
still a member of that group and the surgery is the same one they quoted
in your letter. Good Luck Nancy Poe
— NANCY P.
August 25, 2002
I have my approval letter in my scrapbook and it was almost the same exact
wording. I too recieved my approval letter on a weekend and had to wait
until Monday to confirm what the letter meant exactly. Monday at 8 01 am
(one minute after opening) they explained those terms are a YES!!!
Congrats and all the best of luck to you!! Tonya
— Tonya H.
August 25, 2002
I have not looked at your profile yet, but I would bet that you have one of
the blue cross/ blue shield companies for insurance. They are famous for
"retro reviews" which basically means that the doc provides the
care, then they review the records and determine if the care was
appropriate. As long as you meet criteria and it is in your plan you will
be fine. Congratulations!!
— Vicki L.
August 28, 2002
This is exact wording from my APPROVAL letter. that is only a disclaimer
to make sure you and your surgeon know that if you change or lose your
insurance coverage it won't be covered.
the interesting thing with mine is that they pay 90% for in network, 80%
for out of network but regardless I have a $1500.00 out of pocket max
whether it is in network or out of network.
— **willow**
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