Check insurance documentation requirements before major surgery.
Insurance carriers sometimes require prior authorization and information about medical necessity for the more extensive types of medical treatment, including care, equipment or medication. Medical necessity is a clinical term used to describe the need for this insurance coverage. Insurance carriers often require specific documentation to prove medical necessity.
Definitions
The medical treatment must be reasonable, necessary and appropriate, according to standard medical practice (Cigna, 2010). Medical care is performed to diagnose or treat an illness or injury that will improve or prolong the patient's standard of living. Some insurance carriers have standardized forms, while others require a detailed letter explaining why the treatment is necessary.
Requirements
In the documentation, the physician must provide a diagnosis, prognosis, previous and future recommended treatment methods, an assessment of the illness or injury, and the patient's history, current health and treatment plan. The physician's diagnosis should be detailed and include all injuries and illnesses related to the requested treatment or medication. Medical evaluations such as blood pressure, body temperature and any other diagnostic test results may be required, including X-rays and scans. A contact office number, fax number and mailing address should always be provided.
Advice
Incomplete documentation can delay or deny treatment or payment. Delays or denials can impact a patient's health, resulting in damage or continued injury. To prevent an unfavorable decision, the physician and the insured should be aware of the insurance carrier's rules. Contact your insurance carrier for information about their definition of medical necessity and the documentation that they require.
Tags: illness injury, information about, insurance carrier, medical necessity, medical treatment, medication Medical
