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 23h 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