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...
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.
Note:
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.
These are the steps taken:
Providers will submit the claim.
Insurance carrier will request your medical records pertaining to your current plan and past history.
Insurance sends documents to their medical review board.
Documents will be assessed.
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 Healthcare 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.
