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You’ll want to get pre-approved (or receive a prior authorization) for your surgery. Pre-approval is almost always required for bariatric surgery. Typically, your surgeon’s office will submit the necessary information to your insurance provider in order to seek pre-approval. However, if they don’t, you’ll want to seek pre-approval on your own.
When seeking pre-approval, it’s best to contact your insurance provider in writing and request a determination of your coverage amount before your procedure (to ensure receipt of your letter, send it by certified mail and file a copy of the individual’s signature who accepted it). Again, make sure to request this in writing (see a sample letter here).
Make sure to follow-up with your insurance company. If you haven’t received anything within a week of speaking with them, call back and confirm your materials have been received.
Insurance Provider and Reviewing Claims
Your insurance provider very carefully reviews your claim and looks for two main things:
- Which procedure/benefit you are trying to access
- Reason why you are accessing this benefit (if available based on your policy restrictions/exclusions)
The procedure or benefit you’re trying to access will be coded using a CPT code. These codes originate from the American Medical Association and allow physicians to record the treatments provided to allow for processing of your claim.
The “reason” for the treatment will be represented by an ICD-10 code. This tells the insurance company your doctor’s diagnosis and why treatment is needed. These are the codes and processes used to determine whether or not a claim will be covered under your policy.
Learn more about your insurance.
This content is adapted from The OAC (Obesity Action Coalition) Insurance Guide.