insurance

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Shawn, I can't help with the insurance because I didn't have mine under PPOM, although I have it as a co-insurance some how.   I just wanted to say thanks for confirming that COFINITY is what was formerly PPOM.   I just got my new card today that has COFINITY on it instead of PPOM.  I basically have PPOM because my PCP is not a provider for my primary insurer but is for PPOM plus he is on staff of a hospital that is out of network.  I basically think that I pay for the PPOM/COFINITY benefits they pay in the amount that I have to pay weekly for the extra coverage.   I never had to deal with them because the primary insurance determines if they are a COFINITY provider and pays their rates.   Confused yet?  I am.  Now I have to determine whats a TIER 1, TIER 2, or TIER 3 provider is. The other confusing thing is that I got a BCBS card in the mail also and no where on it does it say that it's for the dental!!! Good luck with your consult. Jeanne

Go for It! My first appeal (they approved me for wls right away-after my surgeon's office submitted my paperwork--I did have guidelines though!-but I wanted VSG and it was considered experimental and they had to be "convinced") was 85 pages (research, studies, letters from docs, copies of everything required, etc.) and my second appeal (to hubby's employer-self insured company) was 99 pages.  They still took 6 weeks to approve it--but they did approve the procedure! I was not going to take no for an answer! I was ready to resubmit if I got a denial on that level. Don't know how many pages THAT one would have been! Martha

I can't wait to see how many pages of documentation I end up with...I've requested all the way back to 1997.  Bury them with paper is my new motto!

PPOM Confinity is a  pricing company not the provider of the benefits.  You want to look on your card to see who is the third party administrator.   They are ones who can tell you what the requirements for surgery are.  All PPOM or Confinity does is reprice claims and forward them to the third party insurance company to have them paid out for network providers.  That is why they could not tell you any of the information or send you the required fax that you wanted because they have to contact the third party administrator for the information and that could take weeks.  It sounds like that you work for a hospital that administers there own insurance policey for their employees so you might want to contact the benefits department.  Good luck with your surgery process. 

Tricia, That's my situation, a hospital administering it's own insurance. My card clearly has both names on it the hospital plan and Cofinity.  My queston is why do I see patient's admitted to the hospital with PPOM as their insurance.  I knew that it was a pricing plan but didn't know what you called it.   And yes PPOM couldn't tell me the bariatric benefits that had to come from the third party. The good thing is that most hospital accept the pricing plans. Jeanne

It is because the hospital is a participating provider with PPOM or whatever there new name is and so when they submit the claims they have to go to ppom for pricing then ppom will forward the new priced claim to the third party administrator.  So if you go to a provider who does not accept ppom then your claim will be sent directly to the third party insurance plan and be paid as out of network.  You want to look at your   insurance card and look for the insurance company which is listed as the non network provider and that is the third party administrator who administeres  your benefits and would have the copy of your plan and would know what the requirements for bariatric surgery. Hopes this helps.  Tricia

my card says Central Care (hospital), ABS (3rd party) and Cofinity...I'm very confused :-)

ABS is the 3rd party, that's who I called.   I called my HR too.  we'll see how much help they are.  i called ABS bagain today, still nothing in writing (ie fax).

I had mine done on 8-29-07 through PPOM.  My third party administrator was FiservHealth.  I had to have six months diet documentation and they had other things that had to be done and sent in, and once it was all done, I had not problems at all getting approved.  Good look and hope you get approval soon!