Commercial Insurance Carriers develop Medical Coverage Policies/Clinical Guidelines as a basis for the reimbursement for medical procedures. Since many are updated at varying intervals, it is important to regularly review as many of your Commercial Insurance Carrier's Medical Policies/Clinical Guidelines as possible for important changes. The Carrier's websites typically allow you to search for this information by procedure name and/or CPT/HCPC code.
Most Medicare replacement plans offered by Commercial payers have to follow the medical coverage policy issued by the state's Medicare Fiscal Intermediary. Non-medicare plans can choose to follow the same policies or they may have their own set of coverage rules. True Medicare Supplement policies must follow the Medicare coverage guidelines. For example: if Medicare pays, they pay.
It is extremely helpful to know this information and keep it close for quick reference. This enables you to notify the physician as soon as possible if an ordered procedure is not covered by a patient's insurance plan. This gives the physician and patient the opportunity to discuss other possible treatment options that are covered. If it is determined that the non-covered procedure is the only option, you will now be able to contact the Insurer for a possible pre-service review of medical necessity and coverage. (Always have on hand the pre-service review process and/or any required forms for the quickest initiation of procedure review.) This is much more efficient than a post-service appeal and is usually favorable.
By knowing the Coverage Guidelines, the patient can have the best treatment without bearing the cost of a non-covered procedure and the provider receives full reimbursement in a timely manner.