Kyra112

Tricare: How long did it take...

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Hey guys,

Another tricare question, lol.

How long did it take for your guys' referrals to be processed and show up on Tricare's [Triwest specifically] website, or to get a phone call?

Im askind because my PCM submitted a referral last Tuesday, and it takes up to 5 business days to process, and i though it was supposed to show up on the website or that id hear something by now [because today is the 5th day] but i havent yet, so i was wondering how long your guys' took? And did anyone have trouble with this process, like they say they didnt recieve anything for you or something?

It's just nerveracking, lol, all answers are definetly appreciated.

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Okay. Referrals inside the system are faster. Referrals to outside I think they actually have 10 days. It's five days *inside* the system(central appointments must call within five days of an internal referral being ordered), and I normally receive my authorization about 2 weeks after an outside referral has been put it.

Also... When they put in my sleep study referral, my doc forgot to put in a letter of medical necessity, which held it up in the system. Tricare didn't call me to let me know, and my doc didn't know, so when I called (and happened to get a wonderful woman from the MTF) I found out and had to follow up. So there are things that can hold up your referrals in the system.

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I have Tricare prime overseas, and I went to my PCM last Thursday and the Tricare lady called me yesterday (Wednesday) and made the appointment with the surgeon for June 7th...so it's going really fast for me. Good luck to you

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insurance stuff is the biggest pain when trying to get the surgery done. I hope things go smooth and quickly for you. It has taken 4 months for my insurance stuff to get settled but I have medicaid.

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I am tricare prime with triwest. Mine took two days from submission to referral.

My tricare advocate even called me before the referral to let me know to call her if I needed anything.

Paul

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Everything was submitted to Tricare for me just today. I'll keep you posted and let you know when the answer comes through.

Hang in there!

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Hey! heres a little update:

I switched surgeons, and i called the surgeons clinic today, and they recieved my referral from my PCP, and when i explained to them how my insurance worked, they looked into it, and an hour later called me back to let me know that i was right,and a referral approval through tricare was unecessary since im Standard, and my consultation is set for May 26, at 11:00 am!!

im so excited and happy to finally just get the ball running!

But i have a new question:

I heard Tricare is now requesting 5 years medical history....

Do these 5 years have to be like, consecutive? I mean i dont do yearly visits to the doctor...and since i moved cities a few years back, ive had a different doctor...how did this work out for all of you??

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Hey! heres a little update:

I switched surgeons, and i called the surgeons clinic today, and they recieved my referral from my PCP, and when i explained to them how my insurance worked, they looked into it, and an hour later called me back to let me know that i was right,and a referral approval through tricare was unecessary since im Standard, and my consultation is set for May 26, at 11:00 am!!

im so excited and happy to finally just get the ball running!

But i have a new question:

I heard Tricare is now requesting 5 years medical history....

Do these 5 years have to be like, consecutive? I mean i dont do yearly visits to the doctor...and since i moved cities a few years back, ive had a different doctor...how did this work out for all of you??

I was worried about the 5 yr thing too...but I didn't have to have it.

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I was worried about the 5 yr thing too...but I didn't have to have it.

oh really?, I hope that happens to me...maybe its just a Prime thing??

Do you have prime or standard??

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I'm on Prime. It seems to vary from region to region. For me I started in August 2009 to get the ball moving. I'm finally scheduled for surgery May 2010.

Once I was done with all my requirements. (and a 5 yr history was not of of them) It took almost 3 months to actually get a date.

It just varies from region to region and doc to doc. There does not seem to be much consistence.

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On the tricare website for what is needed to be approved for WLS it does not say anything about 5 years of medical history. If you know of where to find that written down I would love to know. I think its just hear-say, since I can't find it. Or maybe it's a 'used to be' thing and is not required anymore.

I will be put on tricare on May 21st, and I am SOOOO FREAKING EXCITED! I will be watching this thread and I hope you keep us posted. I have read all of tricare's website.

Good Luck!

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Mine was sent in on or shortly after 03/19 and I called the Dr on 04/02 to see if they'd heard anything (I was gonna call TriCare) and I found out I'd been approved. My surgery was on 04/26. I didn't have to do the 5 year thing, but I did have to do the Psych consult. I got out of the sleep study even tho I also did have to see the Pulmonologist.

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On the tricare website for what is needed to be approved for WLS it does not say anything about 5 years of medical history. If you know of where to find that written down I would love to know. I think its just hear-say, since I can't find it. Or maybe it's a 'used to be' thing and is not required anymore.

I will be put on tricare on May 21st, and I am SOOOO FREAKING EXCITED! I will be watching this thread and I hope you keep us posted. I have read all of tricare's website.

Good Luck!

It's in the handbook, and the tricare check off sheet for evaluation. Some require it some don't just luck of the draw. My friend needed the 5 year documentation...and I didn't but she is in the states and I am in Germany

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It's in the handbook, and the tricare check off sheet for evaluation. Some require it some don't just luck of the draw. My friend needed the 5 year documentation...and I didn't but she is in the states and I am in Germany

Is it in the section for Gastric Bypass? Because this is what they require and it doesn't say anything about 5 years history?

TRICARE covers gastric bypass, gastric stapling and gastroplasty to include vertical banded gastroplasty and laparoscopic adjustable gastric banding (Lap-Band surgery) is covered only when the beneficiary meets one of the following conditions:

Is 100 pounds over ideal weight for height and bone structure and has one of these associated conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome, hypothalamic disorders or severe arthritis of the weight-bearing joints

Is 200 percent or more over ideal weight for height and bone structure

Has had intestinal bypass or other surgery for obesity and because of complications, requires another surgery (takedown)

(Updated Aug 2009)

Or...does it say that for any treatment they require 5 years? Maybe the handbook and check off are out of date? Any direction to exactly where I can find this information would be greatly appreciated, I'm searching the site right now.

Other insurances (In this case Aetna), require 5 years and state it on their website UNDER gastric bypass requirements to be qualified:

Aetna

What you need to know:

Patient needs to get 5 years progress notes from Primary Care Physician. Aetna will not start reviewing without that along with Letter Of Medical Necessity. They will look to make sure BMI (Body Mass Index) has met requirements for 5 years, verify co morbidities and make sure that they have done a 6 month physician supervised diet in the last 2 years with monthly weigh ins and notes about the diet. See below for more details. Make sure to get everything entered in their computer when calling for benefits because if things are sent without initiating it over the phone, they will disregard.

Requirements taken from the policy:

I.

1. Presence of severe obesity that has persisted for at least 5 years, defined as either:

a. Body mass index (BMI (BODY MASS INDEX))* exceeding 40; or

b. BMI (BODY MASS INDEX)* greater than 35 in conjunction with any of the following co-morbidities:

i. coronary heart disease; or

ii. type 2 diabetes mellitus; or

iii. clinically significant obstructive sleep apnea (i.e., patient meets the criteria for treatment of obstructive sleep apnea set forth in Aetna CPB 004 - Obstructive Sleep Apnea: Diagnosis and Treatment); or

iv. medically refractory hypertension (blood pressure > 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management);

Edited by Kupcake

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I just found (and saved to my hard drive) the latest copy of the Tricare handbook. It was updated in November 2009. I read through the whole thing, then i used the search function for the words 'history' and 'gastric' and there is nothing there about a history needed written there.

When I go to the doctors, if I find anything with this requirement I will scan it into my computer and show you guys. But I really think that it is something that is out dated (I really hope so!).

I am open to conflicting information, because I want to be aware as possible.

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I just found (and saved to my hard drive) the latest copy of the Tricare handbook. It was updated in November 2009. I read through the whole thing, then i used the search function for the words 'history' and 'gastric' and there is nothing there about a history needed written there.

When I go to the doctors, if I find anything with this requirement I will scan it into my computer and show you guys. But I really think that it is something that is out dated (I really hope so!).

I am open to conflicting information, because I want to be aware as possible.

Ask Tricare to fax you the eval sheet...the 5 year is on it. And in the handbook we were given when we got here it is in there...it was revised in 2010

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Ask Tricare to fax you the eval sheet...the 5 year is on it. And in the handbook we were given when we got here it is in there...it was revised in 2010

It's weird as much as tricare is a stickler for everything being right, if that is needed then why have I only heard of one person (and that was second hand) needing it. I hope they don't require it here, or I will have to wait 5 years and that would bite!

I will call them tomorrow and I will ask for that sheet and their newest handbook, because I guess November 2009 isn't the newest. Thanks for the info!

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It's weird as much as tricare is a stickler for everything being right, if that is needed then why have I only heard of one person (and that was second hand) needing it. I hope they don't require it here, or I will have to wait 5 years and that would bite!

I will call them tomorrow and I will ask for that sheet and their newest handbook, because I guess November 2009 isn't the newest. Thanks for the info!

You don't need to have 5 years with tricare...you can get dr records showing it from your past

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I have tricare prime and I am in the North region and all my scheduler wanted was to have was 3 yrs of weight history but that was just to make sure if tricare asked that she had it available. I started my process in Feb and have a date in May just waiting for my approval for surgery.

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I'm just scared because I got out of the nave 5 years ago and gave not been to a doctor since. So I virtually have no medical history excep from 5-11 years ago (my military records). I was over weight then too, but not morbidly.

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I'm just scared because I got out of the nave 5 years ago and gave not been to a doctor since. So I virtually have no medical history excep from 5-11 years ago (my military records). I was over weight then too, but not morbidly.

I wouldn't worry too much about it. I was also worried about the 5 year thing (my PCM told me that was the only thing that would be a problem for approval) and I didn't even need it. He wrote down my weight at 14-19 and they accepted it. I was also scared I wouldn't get approved cause Im 19...but I already have me surgeon visit set up and my approval so now Im just waiting for a surgery date.

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Have you always bee obese? Because I haven't. When I got out of the navy I was about 210 pounds. Only a week and a half before I get put on tricare so o guess I should just relax and wait and see.

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Yeah i wouldnt worry too much about it...Im only 17, [18 next Monday, and my surgery consultation isny for about 2 1/2 weeks] But im going to send them records from when i was like...13, because i was in sports and had to get like physicals and things like that, and at 13 i was already about 220 lbs... I think if you just give them what you can, it should be alright..And i heard also [from a very reliable source] that they dont request it so they can see if youve been obese for the the past 5 years, it's just something that they are requesting to just have on file. I wouldnt fuss too much, just get what you got and hope for the best..i dont think they would [or at least the i dont think they should] just deny people for not have 5 years of consecutive medical records...going the the Dr's is expensive! and most of us dont even go unless something is terribly wrong or its required for a job or a sport or something....they should have that understanding i hope...:confused:

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Have you always bee obese? Because I haven't. When I got out of the navy I was about 210 pounds. Only a week and a half before I get put on tricare so o guess I should just relax and wait and see.

Well when I was 8 is when I started getting real big. But no I haven't always been obese (weight wise yes, but body fat wise no). I weighed 203 at 13 and was in all kinds of sports and athletics. When I was 17 I got down to 190 because of constantly running (I played varsity softball, volleyball, and track) then when I graduated I ballooned up to my current weight of 280...that's 90 pounds in a little less than 3 years. My family is a mix between big and skinny people, so it might be genetic.

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I am so relieved that there is no 5 year requirement. I have Standard and crossing my fingers. I'm actually just confused about how much does Tricare pay out to out of network. Is it the "allowable" amount of do they pay everything (except the 20 or 25% of course). My surgeon's office is really confusing me telling me Tricare does not pay much.

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