Addressing Medical Necessity Denials

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Addressing Medical Necessity
Denials
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Addressing Medical Necessity Denials

• Defining Medical Necessity
• As per Cignas definition Medical Necessity means
  health care services that a physician, exercising
  prudent clinical judgment, would provide to a
  patient. The service must be
• For the purpose of evaluating, diagnosing, or
  treating an illness, injury, disease, or its
  symptoms
• In accordance with the generally accepted
  standards of medical practice
• Clinically appropriate, in terms of type,
  frequency, extent, site, and duration, and
  considered effective for the patients illness,
  injury, or disease
• Not primarily for the convenience of the patient,
  health care provider, or other physicians or
  health care provide
• According to recent survey report, claim denials
  cost healthcare practices around 262 billion
  each year. CO 50 i.e., lack of medical necessary
  is considered as one of the most common denial
  reasons. CO 50 means that the payer refused to
  pay the claim because they did not deem the
  service or procedure as medically necessary.
  Denials received due to lack of medical necessity
  are considered as hard denials as its difficult
  to recover the lost payment due to this denial.
  You can upgrade process flow to avoid further
  denials but you wont able to receive insurance
  reimbursements where you are not able to prove
  medical necessity. Its essential to not only
  understand how to solve this problem when this
  type of denial occurs, but also how to prevent it
  in the first place.

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Addressing Medical Necessity Denials

• Common Reasons for Medical Necessity Denials
• While there are many different reasons payers may
  deny a claim as CO 50 (services or procedures are
  not deemed a medical necessity), some of them may
  include
• Lack of documentation necessary to support the
  length of stay
• Service provided
• Level of care
• Reason for admission
• When you receive a denial due to medical
  necessity, reason could be one of the following
• Inpatient criteria not being met
• Inappropriate use of the emergency room
• Length of stay
• Inappropriate level of care
• Guidelines for Appealing Medical Necessity
  Denials
• As mentioned earlier, Medical Necessity denials
  are had denials. While prevention is the best way
  to avoid these CO 50 medical necessity denials,
  there are things you can do to appeal a claim
  thats been denied for this reason. Some of the
  steps include

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Addressing Medical Necessity Denials

• Why sometimes denials have generic denial codes
  and it can be tough to figure out the real reason
  it was denied. Even if you get a CO 50, its a
  good idea to dig deeper, talk to the payer, and
  get an accurate explanation for non-payment.
• Remember to not simply use the original claim
  number, but append to note its a corrected claim
  to avoid it coming back to you again as a
  duplicate claim.
• When dealing with payers, be sure to record
  information like the date, reference number of
  the call, and the person you talk to. This way
  you can reference your encounter if the fight to
  appeal the claim requires multiple phone calls.
• Even once you resubmit a claim thats been kicked
  back for a CO 50 denial, be sure to follow up at
  least once a month.
• When you file appeal claims, ensure appeal
  letters include the claim number, patient,
  service date, provider number and member ID. Make
  the letter to the point and ensure you attach
  supporting documentation. By having everything
  correct the first time, youll prevent having the
  appeal denied.
• While CO 50 is a common denial code, your billing
  team should be better equipped to prevent and
  handle this denial. Medisys Data Solutions is a
  leading medical billing company providing
  complete assistance in medical billing and
  coding. We have great experience in collecting
  accurate insurance reimbursements while reducing
  claim denials. To know more about our billing and
  coding services, contact us at info_at_medisysdata.co
  m/ 302-261-9187

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