Medical necessity refers to a decision by your health insurance plan that your treatment, test, or procedure is necessary for your health or to treat a diagnosed medical problem.
It is not a guarantee of payment until your insurance carrier has received your claims and all medical records are reviewed by their medical review board.
If you are coming in for an egg retrieval and it is a covered benefit, this does not automatically mean your insurance carrier will pay for the procedure as soon as they receive the claim.
If claim is denied based on Medical Necessity, unfortunately, you will be responsible for the denied procedure. Patients do have the right to file an appeal themselves if the provider was unsuccessful with their appeal.
These are the steps taken:
It’s important to remember that what you or your doctor defines as medically necessary may not be consistent with your health plan’s coverage rules. Before you have any procedure, especially one that is potentially expensive, review your benefits handbook to make sure it is covered.