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Medical Necessity

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.

For example...

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.

Note:

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:

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    Providers will submit the claim.
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    Insurance carrier will request your medical records pertaining to your current plan and past history.
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    Insurance sends documents to their medical review board.
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    Documents will be assessed.
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    Decision will be made based on records received if your treatment meets the criteria of Medical Necessity.

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.

To avoid unwanted health-Care billing
surprises, be sure to ALWAYS:

• Ask your insurance company what costs
you must pay out of pocket for your doctor
visit, test, procedure, or surgery.

• Bring your most up-to-date insurance
card(s) to every doctor appointment
and health care visit.

Office Location

115 E 57th Street, 11th Floor

New York, NY 10022

(Between Park Ave & Lexington Ave)

Open in Google Maps

Office Hours

Monday-Friday
7:00am – 5:00pm

Saturday
8:30am – 3:00pm

Sundays & Holiday Hours
By Appointment only

Monitoring Hours

Monday-Friday
6:45am – 12:00pm

Saturday
8:30am – 12:00pm

Sundays & Holiday Hours
By Appointment only