OGB Bariatric Surgery Authorization Form
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Form and authorization requirements for Office of Group Benefits (OGB) plan participants seeking bariatric surgery through Blue Cross and Blue Shield of Louisiana; applies to providers submitting surgery authorization requests for enrolled OGB members.
No material clinical or coverage changes in this revision.
Coverage and Enrollment Requirements
Enrollment-based coverage criteria
Covered when ALL of the following enrollment and pre-operative requirements are met
Completion of the bariatric surgery form (including page 2 clinical criteria) and supporting records must be uploaded to the authorization request in iLinkBlue.
If the plan participant is not enrolled in the OGB Bariatric Benefit Program, the bariatric surgery benefit is not available. The enrollment form must be completed prior to surgery; the form is available online at https://info.groupbenefits.org under Resources > Forms > Members. If the participant is enrolled, include the Louisiana Blue enrollment authorization number on the submission.
Authorization decisions are based on medical necessity and applicable contract terms. An authorization is not a guarantee of payment; services may be denied upon review for medical necessity, contractual limitations, or exclusions. Verify member eligibility, benefits, and any limitations prior to rendering services using iLinkBlue.
Procedure, Diagnosis, and Related Coding
| ICD-10 | ICD-10 Diagnosis Code(s) — provider to supply |
| CPT/HCPCS | Surgery CPT® /HCPCS Code(s) — provider to supply |
| ICD-10 | ICD-10 Diagnosis Code(s) — provider to supply |
| CPT/HCPCS | Surgery CPT® /HCPCS Code(s) — provider to supply |
Authorization Submission & Provider Responsibilities
Initiate authorization via iLinkBlue and attach completed form
Initiate the authorization using the Louisiana Blue Authorizations application in iLinkBlue and attach the completed bariatric surgery form plus supporting medical records to the authorization request.
- Use the Louisiana Blue Authorizations application in iLinkBlue to start the request.
- Upload the completed Office of Group Benefits Bariatric Surgery Form with supporting medical documentation to the authorization.
Complete 4 months supervised weight‑loss program and nutritional counseling
Ensure the participant completed four months of a medically supervised weight‑loss program during enrollment and received nutritional counseling and medical/dietary management as part of pre-operative requirements.
- Document four months of a medically supervised weight‑loss program during the enrollment period.
- Document nutritional counseling and medical/dietary management (diet and exercise) during enrollment.
Upload completed two‑page bariatric surgery form and supporting records
Upload the completed two‑page Office of Group Benefits Bariatric Surgery Form (Page 1 and Page 2 with clinical criteria) and submit medical records supporting compliance with the clinical criteria.
- Page 2 completion (clinical criteria) is required and must be included.
- Submit supporting medical records with the form to demonstrate compliance with criteria.
Provide member, surgeon, facility, accreditation and coding details
Include complete member, surgeon, and facility information in the authorization request, including facility accreditation status and NPIs, ICD‑10 diagnosis code(s), CPT/HCPCS procedure code(s), and proposed surgery date.
- Member: name, member ID, DOB, age.
- Surgeon: contact name, phone, fax, surgeon name, surgeon NPI, address.
- Facility: facility name, address, facility NPI, phone, fax, and MBSAQIP accreditation status.
- Coding: ICD‑10 diagnosis code(s) and surgery CPT®/HCPCS code(s); include proposed surgery date.
Authorization is not a guarantee of payment; medical necessity required
Remember that authorization decisions are based on medical necessity; an authorization is not a guarantee of payment and services remain subject to review for contractual limitations or exclusions.
- Verify member eligibility, benefits and limitations in iLinkBlue prior to rendering service.
- Payment may be denied if services are not medically necessary or are excluded/limited by contract.
Stop if participant is not enrolled in the OGB Bariatric Benefit Program
If the plan participant was not approved for enrollment into the OGB Bariatric Benefit Program, do not proceed — enrollment is required prior to submitting a surgery authorization request.
- If enrollment is 'No', stop and have the participant complete the enrollment form available at the OGB resources site before requesting surgery authorization.
Policy Background
This two‑page form operationalizes enrollment in the OGB Bariatric Benefit Program and documents the pre‑operative multidisciplinary requirements used to determine medical necessity for bariatric surgery. It captures program enrollment status and authorization number, completion of a four‑month medically supervised weight‑loss program, nutritional counseling and pre‑operative nutritional assessment, psychological clearance from a licensed mental health practitioner, and routine testing/evaluations as directed by the treating provider. The completed form and supporting records must be uploaded to the authorization request in the Louisiana Blue Authorizations application in iLinkBlue.
Definitions and Key Terms
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