Insurance Pre-Authorization for Lumpectomy

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Pokemom1959
Pokemom1959 Member Posts: 198
edited April 2021 in Surgery - Before, During, and After

I'm scheduled for a lumpectomy (with bilateral reduction) on 4/16. I had been stressing out because my breast surgeon had not yet submitted an authorization request for surgery (my plastic surgeon did and it was approved). Finally talked to my breast surgeon's office this morning and they said they talked to my insurance (Tricare) and that no pre-authorization for the surgery is necessary - she said she went through each of the surgery codes with Tricare and they assured her that no pre-authorization is necessary. That just seems very weird to me - anyone else have a similar experience?

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  • SpecialK
    SpecialK Member Posts: 16,486
    edited April 2021

    Which Tricare plan do you have? If you have Prime I believe you definitely need an authorization, for the breast surgeon, and the plastic - the hospital likely won’t admit you without one. That has been my experience and I have had a lot of surgery related to breast cancer. If you have Selec you may not need a referral, but I’m pretty sure that for surgery you would still need an auth. You can call Tricare yourself and ask.

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  • Pokemom1959
    Pokemom1959 Member Posts: 198
    edited April 2021

    Yes, it's Tricare Prime. I can call, but I hesitate to. Seems like everyone gives you a different answer. I was told my the facility that did my diagnostic mammogram that I did not need a pre-authorization but I called and Tricare said I did. They put in for it, it was approved and then cancelled because they said I didn't need it. Unfortunately, I don't have the exact codes that the breast surgeon will be billing under so I can't ask the specific questions. Plastic surgeon already has approval and they approved the facility through her authorization. I swear, if this surgery doesn't go forward on 4/16 because of this issue, I will be LIVID.

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  • Pokemom1959
    Pokemom1959 Member Posts: 198
    edited April 2021

    Huh - apparently Tricare has a "Prior Authorization, Referral and Benefit Tool" online ... I looked up the code for a lumpectomy and put it into the system and it looks like I don't need prior authorization as long as I have approved referral to the surgeon, which I do. Very surprising.

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  • SpecialK
    SpecialK Member Posts: 16,486
    edited April 2021

    Make sure the hospital doesn’t need one, particularly for the anesthesia services. In most situations referral management can back date the request for auth, except in the case of a non-Tricare provider. The hospital will likely be the biggest bill

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  • Pokemom1959
    Pokemom1959 Member Posts: 198
    edited April 2021

    Thanks - I will.

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  • Salamandra
    Salamandra Member Posts: 1,444
    edited April 2021

    Sorry you have to deal with this and good luck!

    Are you a Pokemon Go player?

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  • Pokemom1959
    Pokemom1959 Member Posts: 198
    edited April 2021

    LOL .. not really, although I do have it on my phone and played a little. I actually took the screen name when my kids were small and really liked Pokemon ... back in the 1990's. People still seem to get a kick out of it.

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