BCBS Prior-approval for out-of-pocket...worth the trouble???

Sleeper · Post by **Sleeper** » Wed Jan 18, 2006 10:55 am

Well, I'm done with the CPAP trial.... I went to the doctor yesterday and told him I'm ready to buy a Remstar Auto out-of-pocket and he said, "yeah, that's a great idea" and wrote me the script... So that's what I'm going to do, but if there's a good chance that BCBS will either partially reimburse me or at least credit my deductible it seems like it'd be worth filing the prior-approval form.

So I'm wondering, has anyone had any experience with this?

Because BCBS won't be able to rent the machine, how does it work? Once they respond to the prior approval, will I just buy it, submit the receipt, and viola.. what if they come back and say, yeah, we'll approve another trial? Duh.

I mean, I really don't care too much if they reimburse me or not at this point... I'd like to save some money but not if it amounts to more hassles.

Opinions wanted!!

Goofproof · Post by **Goofproof** » Wed Jan 18, 2006 12:31 pm

I can't help you about the INS, but if you can afford to get it and get along with making your life better, that's the important part.

yardbird · Post by **yardbird** » Wed Jan 18, 2006 12:47 pm

Sleeper, here's what I'm doing. I have Community Blue which essentially is BCBS (emphasis on the -BS- part... hehehe... bastages...)

I bought my REMStar auto out-of-pocket as my original machine was having technical difficulties. The insurance company basically wanted to send my old one (a straight CPAP) out for repair and have me make an appointment with my sleep doc. I made the appointment in December FOR FEBRUARY!!! It was the soones I could get in. They said they were going to send me home with an auto machine. I said, "That's what I want to BUY!" ... hassle... hassle ... hassle ... no end of excuses, rules (I love the -participating provider- part... "OH! You mean the one that pays kickbacks to my sleep doc? Is that why they're listed as participating? How absolutely convenient!)

Anyways... bought what I needed and now I just keep sending them paperwork in an attempt to get at LEAST the 50% reimbursement for "out of plan expenses".

If you can afford to get your equipment... get it. Then hassle THEM and give THEM stuff to respond to. Try to follow the rules first. You never know. THey may just pay for it, but in my experience they won't. THEN you keep writing letters and sending them paper. Sooner or later maybe someone over there will just throw up their hands and "just pay this guy. He's a pain in the a**)

Janelle · Post by **Janelle** » Wed Jan 18, 2006 1:13 pm

Check with Bill My Insurance located on this website. Check out the headers. I got my last masks through them, and all I had to do was give them my Dr.s name, etc, and copy of my original RX for their files. They called BCBS, got the letter of necessity and everything. I had my new masks in like 10 days or less, versus having the DME just getting the Letter of Medical Necessity in 2 weeks.

BCBS and other insurance companies pay a set amount for a CPAP,APAP or BIPAP, separately for the hose, the mask, filters, humidifier. Even with the deductible you are probably going to come out owing very little out of pocket.

NightHawkeye · Post by **NightHawkeye** » Wed Jan 18, 2006 2:33 pm

I called my BCBS provider before purchasing my machine on-line and was told they preferred to do the rent-to-own thing but that they would pay the out-of-network rate if I purchased on-line, but that I would have to submit the paperwork myself. This sounded not so bad so I later got instructions to find the claim form on-line (not easy), and sent the claim in a couple of weeks ago.

Just checked status on-line and there is no record of the claim yet, so I'm in a holding pattern . . .

Regards,
Bill

Lyn · Post by **Lyn** » Wed Jan 18, 2006 11:02 pm

NightHawkeye wrote:I called my BCBS provider before purchasing my machine on-line and was told they preferred to do the rent-to-own thing but that they would pay the out-of-network rate if I purchased on-line, but that I would have to submit the paperwork myself. This sounded not so bad so I later got instructions to find the claim form on-line (not easy), and sent the claim in a couple of weeks ago.

My BCBS was just the opposite. They paid for the machine immediately ... did not want to rent at all, although that's what the first BCBS rep told me they would do. Actually, she said that they would rent it for as long as I needed it. Also, they told me that if I bought out of network that I would have to meet another $1000.00 deductible over & above the in network deductible I had already paid. I called BCBS 3 times, asked the same question all three times & got 3 different answers. Was finally told that the claim would have to go through first & THEN I could call & discuss it if it wasn't right.

Lyn