‘Not medically necessary’ denials generate from many policies and vary from carrier to carrier. With these cases, we have an opportunity to obtain payment, but only after submitting medical records and a supporting letter that demonstrates the validity (medical necessity) of the service. ![]() ![]() A greater challenge comes from denials that are created from the broad range of ‘not medically necessary’ issues. We may have a denial for missing authorization, and a quick explanation of the ‘blind provider’ scenario will generally get those cases paid. Those denials are out of our hands, and billing the patient is the only resolution. We may have a denial for a patient who has used all of their benefits for a year, or has a large deductible. What sort of denials do we see on a daily basis? Success with those denials is contingent on the situation and the quality of the documentation that supports the service. ![]() Handling those denials effectively is our highest priority. But we work in a less than ideal world, and claim denials are a part of our daily work. ![]() In the ideal world, all claims for medical services would be paid without question.
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