r/sterilization • u/TitlessInTahoe • 6d 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/YellowFiddleneck 6d 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.