Have a question about my "Notice of Certification"

Hi again. I saw where some of you ladies have experience with all the insurance mumbo jumbo and I have a question for you(or anyone that can answer this for me). I got approval for my hyst. from my insurance co.(Aetna managed Choice), also approval for a 3 day hospital stay and then on Friday I received the news that the insurance covers this procedure 100%, yada yada yada. Ok, so, now today I receive in the mail a "Notice of Certification" and on it, it gived the usual lingo for inpatient services and that the Certification Decision is *certified*(I'm assuming this is another word for approved? I dunno)but, I see on this paper under *remarks* that this same certification letter is being sent to my OB/GYN(fine), the hospital where the procedure is to be performed(great) and to my Primary Care Physician(this is where I start to worry). I have never seen her for any gynecological problems, ever. I go to her for everything else, though. As far as I know, I don't have to get a referral to see my OB/GYN(have never had to)and the only tests and attempted treatments before the decision of the hyst. came about, have been performed by my OB/GYN without(again I'm assuming)any referral from my PCP. Sooooo, my question is, what happens when my PCP gets this letter and doesn't agree to it?(if that's the case) Will this cause a cancellation of my surgery and cause me to have to "duke" it out with her? I mean, why are they even sending her this letter if I have never had to get her approval to see my OB/GYN?
I have, however, had to get her approval once to take my daughter to an ear specialist.... Is she being informed out of courtesy(standard procedure), or can she really change the *stats* of my surgery? Does she actually have a say-so in this matter? I'm very ...

Any help on this is GREATLY appreciated!

Hi Julie,

I think it's done as a courtesy. I have a primary care gal who I go to once in a blue moon, but she's notified of everything because she's on file as my PCP with the insurance company. I can't imagine that your PCP would call a halt to this at this late stage, especially considering he/she knows nothing about your current condition... and even if they did disagree with the treatment, I'm sure they'd call your Gyn to voice that opinion instead of your insurance company.

It sure is stressful trying to get everything to fall into place, isn't it? I'm sure whatever : I have after surgery will be just as much about an end to the hassles as it is about no longer being in pain!

Hang in there! This is gonna work out

Heidi

Hmmmm...that's a good question. My insurance requires referral from PCP before it pays for any "specialist" involving my health care...but I'm on HMO...not "managed choice". I have to use specialists and hospitals that are "in network" also...unless I want to pay full price. What does your insurance co. papers say the process is for "managed choice"????? Is referral mandatory???

To be absolutely sure about it why don't you call your insurance company tommorrow? I think letting the PCP know is a courtesy, but it wouldn't hurt to check it out, just so you have some peace of mind about it. I worked in an ophthalmology office and normally aetna did require a referral to our specialists, but every plan is different. If your HMO is like mine your gynecologist has probably been sending your PCP consultation notes on you all along. H/she will also get a report on your surgery to keep in your chart. This is just something they always do for the primary physician. Also, all lab reports are normally sent to the PCP.

I'd call and make sure about it.

Sherry

Hi Julie!

I agree with the previous posts. I think they sent the letter to your PCP as a courtesy. I would call them just to make sure though. They might have sent it to your PCP in case he/she decides to stop in and see you at the castle while they are doing their rounds. Not quite sure, but just a thought.

Please let us know what you find out.

&

Dot and all,

I only *wish* I had the papers. We have had the same insurance for over 6 years and I dunno what happened to those papers when we moved. Lost quite a few things. *sigh* But, I do know that I have to get a referral from her to see anyone not associated with the doctors 'in' the Centre for Healthcare(this is the name of the building where all of our doctors are). My family and I can see *them* at anytime for anything without even consulting her(this includes any specialists too, as long as they are a part of the Centre)but if I want to see a specialist outside of this network of doctors, then I need a written referral slip. At the time when my youngest daughter needed to have her hearing checked, the Centre didn't have an ENT specialist, thus I had to see an ENT that was at a different complex, but was still a participating doctor under my ins. plan. As far as my OB/GYN goes, I see him anytime I need to without going and getting a referral from my PCP and everything he's ever done to me in the past(including my DnC and tissue removal in Oct. 2001)has been covered without any hassles. Seeing as this is going to be a major and permanent surgery, I just don't know where she fits in *powerwise*. I hate calling the ins. co. for fear that I may start something. I'd rather be lost in the pile of papers they have..

Hi Julie,

I got to thinking about your situation, and since I have Aetna I looked in my plan book thingie to see if I could come up with anything.

It says front and center that whether you're PPO, HMO, or whatever, that you can self refer to a gynecologist.... so, it shouldn't matter whether your PCP is on board about the decision or not for there to be coverage. We may not have the same program through Aetna though, so I would still verify that with them for your own peace of mind. I think it'll be just fine though

Heidi

Thank you SO much!! That was super nice of you to do for me! I really and truly appreciate that.... That was like getting a ..... I'll call just for my own peace of mind, like you said, but I feel about 99% sure that your booklet probably applies to me, too.

Thanks again! SO much! =o)