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Documentation needed for insurance to get a power chair and air cushion

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    Documentation needed for insurance to get a power chair and air cushion

    Hi,

    I have BCBS for the first time and I need a new power chair and air cushion. Anybody knows what documentation I need from my family doctor or neurologist to be sent to BCBS in order to be paid back? Thanks

    Skyhawk
    C6/C7

    #2
    Most often you need PRIOR authorization for a chair and cushion. If you just go and buy one, and then send them the bill, it is unlikely to be funded at all. Many insurances, including BCBS in most states, now use the Medicare regulations for power w/c as their method for prior authorization as well, meaning that you must have a power chair evaluation by a RESNA certified therapist (OT, PT, KT, etc.), who also then writes up the prescription and medical justification for the chair features you need, and this is signed by your physician as the "letter of medical justification" for the chair. This is submitted to the insurer, and then they decide how much of this they will pre-authorize (which is usually done for each additional special feature or accessory of the chair past the basic chair configuration.

    For example, they may approve a tilt-in-space seating system if the justification is convincing enough that this is the only way you can do weight shifts to prevent pressure ulcers, or you need it for blood pressure management. Features such as a rising seat are VERY difficult to get medical justification for, so you may have to pay for that part of the costs out of your own pocket.

    (KLD)
    The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

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      #3
      We replaced Ry's chair a few years ago under BCBS because he literally outgrew the old one. He was only 17 when he had the original seating eval so we knew then that he would outgrow it. The only thing we had to do was see the DME provider and after completing the measurements, they contacted his doctor (family doc) to get the script worded right.

      We now have a manual chair in process as Ry really thinks he can do it. This involved a PT eval but as he is doing therapy at ODU, this was not an issue. She thinks he can do it and he wants it so badly. The doc still wrote the script, the PT added the eval and the DME provider managed it all. We are waiting since it all has to be pre-approved but we are hoping to get it before winter so he can practice at the park on the sidewalks.

      --eak
      Elizabeth A. Kephart, PHR
      mom/caregiver to Ryan-age 21
      Incomplete C-2 with TBI since 3/09

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        #4
        In that case, for the air cushion I would only need a prescription from my family doc along witha report from my neurologist about my injury in order to get a pre-authorization, right?

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          #5
          You should not even need the report from the neurologist. Ry has not seen one in years and his family doc has taken care of all his DME needs. We replaced the air bladder (J-3) last month with only a few phone calls.--eak
          Elizabeth A. Kephart, PHR
          mom/caregiver to Ryan-age 21
          Incomplete C-2 with TBI since 3/09

          Comment


            #6
            Thanks. That was a relieve. It hurts to have a $50 copay to see a specialist. I'll get all the prescriptions I need ( air cushion, wheelchair, catheters and leg bags) from my family doc. I hope it works.

            c6/c7

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              #7
              Bcbs il

              After calling BCBS to know my coverage for wheelchairs and being on the phone for AN HOUR they said that I have to pay the first $3000, even after I told them that it was a medical need and the wheelchair was needed for indoor to be able to perform my daily basis. Unbelievable! I pay each month to my health insurance to get this in return. This is the system that we have to fight against. Criminals with ties. Sorry, I had to vent.

              C6/C7

              Comment


                #8
                It sounds like you ay have a high deductible plan. If this is the case, you should also have an HSA to go with it. Or is the $3000 deductible only for DME? Plans come in many different variations.

                You are right about the criminals with ties. Even those that claim to be non-profit have many levels of execs that make too much money and when they own the local hospitals, they literally own the doctors since that is where their revenue is coming from. To think that they are getting rich off of other people's illnesses and injuries makes my stomach turn. Now I hear that Anthem (BCBS) is 90% towards approval to purchase CIGNA. They claim that it is necessary to control costs. How about the get rid of three levels of management to control costs?

                Is your BCBS an employer sponsored plan? Do you have the option to participate in an FSA to help with the deductibles? While you still have to pay it, you save tax $ without having to meet eligibility for a deduction (excess of 7.5% of AGI) and in essence allows you to be reimbursed as soon as the expense is incurred and continue contributions to the FSA for the rest of the year, like free financing.--eak
                Elizabeth A. Kephart, PHR
                mom/caregiver to Ryan-age 21
                Incomplete C-2 with TBI since 3/09

                Comment


                  #9
                  Thanks for the info. I'll look at it.

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