When you get a denial letter from your insurance company, it can be overwhelming and stressful. However, knowing the facts about medical necessity denials may help you understand what went wrong and how to improve your chances of approval.
What is a medical necessity denials?
Medical necessity is a term used to describe the reason for a health insurance claim or service. The health plan determines whether an insured person’s medical care is medically necessary, not the doctor who provided it. There are many types of insurance denials due to medically necessary. A denial can be based on the following:
- A medical necessity determination was made by your insurance company, and they determined that the treatment you received was not necessary (or in some cases, could have been provided with less expensive treatment).
- You did not meet your plan’s deductible or out-of-pocket maximums before being covered for all services under that plan year. For example, if you had an accident on January 1st but didn’t go see a doctor until March 1st because you couldn’t afford it until then – then there is a chance that your claim will be denied because it wasn’t filed within 6 months after becoming eligible for coverage under that particular policy period (i.e., 12 months).
What are some common reasons for a denial?
- Not enough medical documentation.
- Incomplete or missing diagnosis.
- Incomplete or missing treatment plan.
- Incomplete or missing treatment response.
- Incomplete or missing care plan.
Understanding documentation, records and care plans can help you avoid denials due to medically necessary.
- Documentation is important. There are many ways to document a patient’s medical necessity, but the most common methods include:
- These can be paper or electronic records and should include all pertinent information about the treatment sought.
- Care plans. A care plan is a written description of how you will provide care for a patient, including what services are necessary for them to receive proper treatment and why those services are necessary (i.e., medically necessary).
- Procedure and diagnosis codes must match each other for an insurance company or government agency not only to recognize them as valid but also to pay out on claims that utilize these codes!
Being informed about the reason for your denial can help you understand what went wrong and how to improve your chances of approval. Knowing the reason for your denial can help you understand what went wrong and how to improve your chances of approval. Being informed about the reason for your denial can help you understand how to improve your chances of approval.
You can’t fix what you don’t know about, so it’s important that if a claim is denied by an insurance company, they provide an explanation as to why they did not approve it. This gives patients the ability to understand what went wrong with their medical treatment or procedure so that they can work on improving their condition before submitting another claim in hopes of getting reimbursed by their health plan again.
Conclusion
There are many reasons why your insurance company may deny coverage for a medical procedure or treatment. Knowing the facts and understanding what caused your denial can help you avoid future denials due to medically necessary.
By understanding documentation, records, and care plans, you can avoid common reasons for a denial like incomplete information or lack of authorizations needed by doctors before they can proceed with treatment plans. There are also ways that patients can improve their chances of approval including filing appeals quickly after receiving notice of an initial denial as well as providing more detailed explanations regarding why their case fits into a specific category under policy guidelines such as being disabled.
To learn more about medical necessity we have published other articles on the topic. Please reference.
