question about requirments - Page 2 - ThinnerTimes

Angel~in~KY · 05-14-2008, 11:17 PM

I just want to start by saying that there are many forms of UHC insurance and they are NOT all the same in coverage. I have United Healthcare Choice Plus (I believe that's what it's called, it's a high coverage option). So, I can't be sure that my information will match yours but here it is. Notice there is no requirement of 6 months of diet, but if you have to wait for coverage anyhow you might as well start documenting just in case.

Requirements:
In-Network Provider
In-Network inpatient covered only when a diagonis of morbid obesity exists
Covers surgical inpatient provided:
covered person must have bmi 40
documentation of a diagnosis of morbid obesity min 5 years
over age 21
Surgery must be performed at In-Network hospital by In-Network surgeon

Must submit predetermination:
Doctor's Letter

Covered 90% of eligible

mommyto-3 · 05-14-2008, 11:46 PM

Mine is United Healthcare Options PPO. From what i hear it is suppose to be one of the best that they offer, is that the same as your then? I am really horrible at all this insurance stuff.lol.

Angel~in~KY · 05-15-2008, 12:04 AM

My card just says United Healthcare Choice Plus on the bottom. In the area where the group is listed (the employer name) it says the employer name and also says High Coverage Plan.

I used to do data entry for Quest Diagnostics and I know that there are tons of different 'flavors' of UHC insurance. I do know that I had no trouble at all when I called to get info about WLS coverage.

Vikkator · 05-15-2008, 08:58 AM

Debbie is right on this one. I have UHC and called to see if it's covered. They asked me my weight and height and said I'd qualify. I have to pay 10%, but I still think it's a bargain. They do have to give final approval to go ahead with the surgery after i jump through all the hoops, however, even though they said I qualify.

As far as the 6 month diet goes, a lot of that depends on both your surgeon and insurance company. My surgeon requires a 10% weight loss if you opt for the lap-band, but not for the RNY. They (the surgeon) also require me to space out my pre-op visits. For example, I went to the seminar, then saw my PCP, then had an abdominal ultrasound to check my gall bladder, then the surgeons office called me to get started. Then it's the psych eval, and they space out the nutrition meetings (1 seminar then 2 meetings with the nutritionist). Once that is all done, I finally get to meet the surgeon, then I'm on my way.

Some surgeons and/or insurance companies require a sleep study to test for sleep apnea. Mine did not, unless I am already being treated for it, which I am not. I've talked to people who said it was mandatory for them.

So basically it all depends. I don't know about the 12 month waiting period--that sounds kind of far-fetched to me and probably isn't true. You'd think they'd educate these customer service people before they put them on the phones!

mommyto-3 · 05-15-2008, 09:17 PM

I totally agree about the 12 month waiting period. What she told me was that morbid obesity is considered a "pre-existing" condition, and that they do not cover anything to do with a pre-existing condition until you have been covered for 12 consecutive months with them. Like I said though, the last person I talked to a few days ago said she was going to check into that, so hopefully that doesn't really apply to me. Thanks for all the input , It really is helping alot!

astona · 05-16-2008, 06:32 AM

10% is nothing compared to a self pay person. You can claim it on your taxes as well as if you have a medical saving account you can use that money.

Mine was covered 100% by insurance thank god !!!!!

The total was $56,000 ( I had lap-rny) in which my insurance paid $9k and I was told I didnt owe anymore. So I hope you only have to pay 10% of the 9k and not the 56k, I dont know how that works

Also look for Office and educational fees. Native2u was talking about Dr Fusco that charges 4k in fees, where Dr Jawad only charges 250 pre op and than 100 post op, HUGE difference and NOT covered by insurance.

Please make sure your Dr is a Center of Excellence or at least applying to become one.

mommyto-3 · 05-19-2008, 03:52 PM

so, the lady called me back from the insurance company, just like she said she would.

but, she said the patient advocate still hasn't gotten back with her about all the requirments yet. should be by the end of this week now she says. don't get me wrong i'm happy she did call me back, but geesh, how hard is it to figure out what i need to do?

mommyto-3 · 05-25-2008, 01:13 AM

The lady from the insurance company called back again yesterday. She still hasn't been able to get any definate answers for me, but she had a few suggestions this time.

She suggested getting a letter from my doctor and having it basically state my medical history and weights for 5 years, and any diets I have tried(but said it didn't have to be dr supervised diets).
My question now is....if she isn't positive thats all i need to do, and i do it, send it in and all......is it going to get denied because i don't have all the required info(if there is more that they do require) ??
If it is denied for that reason, can i still appeal. Hoping obviously it wouldn't be denied, but just really worried when she says she still doesn't have all the info.
So, should i go ahead and have my doctor send a letter? Or would i be better off trying to wait until the insurance company gives me a definate list of requirements so I can be certain to get them all done???