Can anyone well versed in HMO insurance (BCBSTX) please help me out on what I'm supposed to do in my situation. This insurance is through the marketplace.

I had to do breast imaging last year and was told to come back in 6 months. When I had the initial imaging done I was using PPO insurance, zero issues.

Now I'm due for my 6 month follow up breast imaging and I'm using HMO (never ever used this type of insurance so totally unfamiliar) so I contacted BCBSTX on what I need to do to get the imaging approved & covered and I am now getting different answers from different agents. I'm so confused and frustrated at this point.

My gynecologist has handled everything to do with ordering and managing my breast care and multiple BCBSTX agents I spoke to said my GYNECOLOGIST would need to send THEM the imaging referral so they could approve it. Just to note, I was told and confirmed that in Texas, you don't need PCP referrals to see a gynecologist with HMO insurance.

I've been trying to get my gyno's office to do that for weeks and they've been confused so it's taken forever. I contacted BCBSTX multiple times to confirm I was doing this correctly and multiple agents said this was what needed to be done.

I followed up today again to see if they received a referral and now I'm being told something completely different after weeks of confirming with multiple agents my gyno had to send them referrals…I always do chat so I can save what they tell me. this is what another agent told me I would need to do, this is almost verbatim apart from what I put in parentheses:

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Find the imagining center in network that can do the breast imaging The imaging center need to request the referral from the PCP. You can set the appointment with your PCP and request it (they clarified that my PCP will send them/BCBSTX the referral directly, not sure why they said the imaging center needs to request from them when they say I can request it too). After they (PCP) send the referral we can approve it As soon as the referral is approved, you can call us to verify how much services they request and that we approved and also to check the coverage of the service You can go to the appointment with your imaging center

I don't even trust what these agents tell me anymore and they said they can't escalate it yet because no claim has been submitted. Can someone please confirm if the steps listed above are correct or what is usually supposed to be done in an HMO to get the follow up imaging covered? Any advice is deeply appreciated, thank you.

submitted by /u/CityofBlueVial
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