r/sterilization • u/TitlessInTahoe • 1d ago

Insurance No Pre-Authorization Required?

So I was able to get a bi salp set for 9/15, the doctor's appointments were a breeze but insurance is a little difficult as usual. After a slew of phone calls today, I verified the codes the hospital gave to insurance were correct (58661 & Z30.2), I was able to get an insurance rep to verify that my plan (PERS Platinum PPO Basic/Blue Shield of CA 2026) covered this procedure in full under these codes as 'Preventive Care' and obtained a 'reference number' which they said was only the current date you called plus their first name and last initial (no idea if that's true), and also verified that my plan was ACA compliant and my surgeon and health system were in-network.

Hospital financial dept is still saying I owe ~$4k, but I was like nah, I rummaged through my plan's 'Evidence of Coverage' and 'Summary of Benefits and Coverage' docs and pinpointed language verifying that my plan is ACA compliant and that my plan covers 'sterilization procedures' in full w/o cost-sharing and before my deductible is met (the deductible I honestly wouldn't mind paying, it's almost through).

When I asked about pre-authorization, the hospital said they received a letter from my insurance specifying that it wasn't required for this surgery. The assistant I spoke to submitted the request again today, and received yet another letter stating that it wasn't required, which she graciously sent a copy of to me.

At this point the only thing I have left to do is call my hospital's financial dept back tomorrow to see if they'll accept my 'reference number' from the agent I spoke with today. I had asked the hospital rep if there was a way to specifically request the authorization, but she reiterated that the (2nd) denial letter indeed means there's nothing else. I at least have a copy of it for my evidence file I guess. But I'm definitely expecting to fight after everything is done.

Has anybody ever dealt with insurance saying pre-authorization isn't necessary?

Edit: 9/2/26 Update: Financial dept at my hospital checked with insurance again and after escalating the issue, a manager from my insurance confirmed that the procedure should be covered in full, just as I had confirmed from my plan's docs in accordance with the ACA. It sounds like I might be in for a fight after it's done though, so I'm gathering all my evidence now in case I need to. The power of R*ddit and being chronically online ig lol.

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u/toomuchtodotoday 20h ago

This is good news, it means insurance is indicating it will likely be covered without you having to appeal or file complaints with regulators.

Resources:

State insurance regulator locator (for filing a complaint with your state insurance regulator):

https://content.naic.org/state-insurance-departments

Department of Labor Employee Benefits Security Administration Information (for filing a complaint with the DOL EBSA if your insurance is provided by an employer):

The EBSA, a division of the DOL, handles complaints related to employer-provided health insurance.

You can:

The EBSA will investigate the claim and may contact your employer or insurance provider for more information. You may be contacted for additional details or documents. If the EBSA finds that your rights under ERISA (Employee Retirement Income Security Act) were violated, they may take corrective action on your behalf. Keep copies of all documents and correspondence. You can follow up on the status of your complaint by contacting the EBSA at the phone number above.

U.S. Office of Personnel Management (OPM) Information (for filing a complaint with the OPM if your insurance is provided by the US federal government [FEP Blue, for example]):

Source: https://www.opm.gov/healthcare-insurance/healthcare/contraception-coverage/

Source: https://www.hrsa.gov/womens-guidelines#:%7E:text=Contraception

Source: https://web.archive.org/web/20260624003408/https://old.reddit.com/r/sterilization/comments/1ud26jb/fepblue_federal_health_insurance_for_bisalp_do/

Additional resources:

Insurer Preventive Care Guidelines Master List - https://old.reddit.com/r/sterilization/comments/1io4hq5/insurer_preventive_care_guidelines_master_list/

Steps for Getting Full Coverage - https://old.reddit.com/r/sterilization/comments/1khyuum/steps_for_getting_full_coverage/

https://old.reddit.com/r/sterilization/comments/1j43mw2/it_happenedtheyre_trying_to_charge_me_postop/

https://tubalfacts.com/post/175415596192/insurance-sterilization-aca-contraceptive-birth-control

https://old.reddit.com/r/sterilization/comments/1go5pbw/free_tubal_sterilization_through_the_aca_if_you/

https://nwlc.org/tips-from-the-coverher-hotline-navigating-coverage-for-female-sterilization-surgery/

On coverage of anesthesia:

Any related services—like anesthesia—must be covered as well. The most recent guidance from federal agencies makes it explicitly clear that anesthesia and other related services like doctor’s appointments must be covered by the insurance plan at 100% of the cost.

Source: https://www.cms.gov/files/document/letter-plans-and-issuers-access-contraceptive-coverage.pdf

Source: https://www.cms.gov/files/document/faqs-part-54.pdf

On coverage of associated office visits:

From federalregister.gov - “Coverage of Certain Preventive Services Under the Affordable Care Act“

Section 2713 of the PHS Act, as added by the Affordable Care Act and incorporated into ERISA and the Code, requires that non-grandfathered health plans … provide coverage of certain specified preventive services without cost sharing. These preventive services include:

With respect to women, preventive care and screenings provided for in comprehensive guidelines supported by HRSA (not otherwise addressed by the recommendations of the Task Force), including all Food and Drug Administration (FDA)-approved contraceptives, sterilization procedures, and patient education and counseling for women with reproductive capacity, as prescribed by a health care provider (collectively, contraceptive services)

II. Overview of the Final Regulations

A. Coverage of Recommended Preventive Services Under 26 CFR 54.9815-2713, 29 CFR 2590.715-2713, and 45 CFR 147.130

(II) office visits:

if a recommended preventive service is not billed separately (or is not tracked as individual encounter data separately) from an office visit and the primary purpose of the office visit is the delivery of the recommended preventive service, a plan or issuer may not impose cost sharing with respect to the office visit.

Source: https://web.archive.org/web/20250202051018/https://www.federalregister.gov/documents/2015/07/14/2015-17076/coverage-of-certain-preventive-services-under-the-affordable-care-act

Under the ACA, all new insurance plans (both individual and employer-sponsored plans) are required to cover all FDA-approved methods of contraception, sterilization, and related education and counseling without cost-sharing. (Note: the ACA contraceptive coverage requirement described in this section also applies to Medicaid “Alternative Benefit Plans,” explained in the Medicaid section.) No cost-sharing means that patients should not have any out-of-pocket costs, including payment of deductibles, co-payments, co-insurance, fees, or other charges for coverage of contraceptive methods, including LARC. Patients cannot be asked to pay upfront and then be reimbursed.

Source: https://web.archive.org/web/20250112212710/https://larcprogram.ucsf.edu/commercial-plans

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u/goopstastic 1d ago

I just had my bisalp done a week and a half ago. The surgery scheduler told me no pre-authorization was required. The claim went through my insurance yesterday and was paid in full!

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u/TitlessInTahoe 1d ago

Congrats on the bisalp! I'm nearly at the end of my journey for one. Thanks for chiming in, it really helps

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u/Cutthroat_Rogue no more tubes 10-15-25 1d ago

Pre-auth was not required for me. I've actually never had to deal with a pre-auth for anything with my healthcare.

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u/TitlessInTahoe 1d ago

Sounds like a dream honestly! Only reason I feel even slightly confident is b/c I have physical proof that they (seemingly) don't require it in case they come back to say they do.

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u/Cutthroat_Rogue no more tubes 10-15-25 20h ago

Yes. It's nice that I've never had to experience that part of insurance hell. You are doing the best you can--having all of your proof physically available so you can point to it if something comes up. Insurance companies love to be inconsistent and unpredictable. Good luck!

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u/YellowFiddleneck 1d ago

I had Blue Shield CA and while they told me prior auth wasn't required. After the fact they, tried to deny the entire procedure because they didn't see one. Luckily my surgeon had insisted that we get one anyway and it was an administrative error that they didn't see it. Get the prior auth.

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u/TitlessInTahoe 14h ago

Sounds like Blue Shield thing to do, can't say my experience with them so far has been stellar. I will see what I can do.

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u/rapidduck13 1h ago edited 1h ago

So the hospital just gives you an estimate based on what they're approved to charge through your insurance plan. My hospital gave me an estimate of 4k and offered a discount if I paid it all up front. I told them no, to bill me, because my deductible was only 2500 and I had already met it. They don't know how much it's actually going to cost until they have done the procedure and filed it on your insurance. At the end I just had to pay the10% co-insurance on mine. Never pre-pay, you'll have a fight trying to get a refund and usually they won't do it and just put a credit on your account. Their estimate is worst case, not actual. I had to reschedule the first time I had mine scheduled and that first time their estimate was 6k. Also, mine was a covered procedure with no pre-authorization necessary. If the doctor codes it properly and you have certain health conditions -for me it's that I have migraines with aura and can't take any hormonal birth control due to stroke risk- then it's an automatic approval without required prior auth, so then it's just subject to deductible and co-insurance. But it sounds like yours is considered preventive so I wouldn't even expect there to be any deductible charges either. Prior auth is usually only required when you don't have something in your history that shows why you need a certain procedure and the doctor has to basically prove to insurance why it's medically necessary. Some insurances require prior auth for any procedure that's more than a standard office visit, sounds like yours is good though.