Are pre-certification 'and' approval the same?

[sandie511]

I’m a little confused. I have insurance through my union, however, I hold a BCBS card but it is the teamsters who pay the claims. That being said, my paperwork was sent to Med-Care to get approval, however Med-Care sub-contracts it out to MCM (Medical Cost Management Corporation). Here is where I get confused, while talking to MCM on some clarification the doctors insurance said it needed (about the diets I have been on for last 5 years), I asked how long does it usually take once she submit the completed paperwork for review…she stated they are only doing the pre-certification to check if the surgery is deemed ‘medically necessary’ and then they send it back over to Med-Care for final approval. What I am getting at is, once Med-Care gets the approval from MCM can they still ask for more criteria to be met. MCM before being sent to their doctors to be reviewed have asked for cardiac clearance, pych clearance, thyroid results in addition to what they have already received from the insurance dept at the doctor’s office. I thought it kind of odd they’d want a cardiac and thyroid clearance before they even begin to review it.

[Belle2]

Hi Sandi,
I'm not the person to answer these questions but I will put my 2 cents in! I have not had the sleeve yet. I am waiting for my final psych visit and last nutritional counsel and be ready to see the surgeon. With that being said, I would call my doctor and insurance and be sure the requirements match. If one says something different than they other keep pushing. My insurance company was giving my doc incorrect information. Cardiac clearance is a must as far as I know. I think I need mine right before surgery. It wouldn't surprise me if they want these clearances before they look at your case. I have found that many times the insurance company does not make practical sense. They often shoot themselves in the foot thinking it will save them money when it won't in the long run. There are a lot of hoops to jump through and each insurance company has their own requirements. I hope someone else here on forums has the same type of insurance and can help you. In the time being, I just wanted to say hello and jumping hoops does go faster than you think. There are a lot of benefits about the decision we have made to have surgery. I wanted it done NOW. I can see that it is ok to go slowly. Belle

[jim1968]

I'm waiting insurance approval from BC/BS.

My doctor submitted only a few days ago but his office said they have been getting approvals in 10-14 days. I'm told they have 30 days to decide, that said all my pre-surgery requirements were complete prior to submission they include, nutritionist consult, exercise consult w/BMI test, upper GI, heart stress test, phyc evaluation, 1 support group meeting, physical from family doctor, sleep doctor exam.

It took me about 6 weeks to complete everything, it could have been shorter but a couple doctors were booking appointments 3-4 weeks out.

I hope to have my surgery date in the next couple weeks, I want to be sleeved and healed up before holidays get here

[tamjoho]

I also have BC/ BS. I have to do a 6 month dr guided diet. My pcp put me on a 1200 calorie diet. I hope they get yo approved quickly. I have all the same things you have done. Did you have to do a diet? Good luck.