Resources to Decrease Denied Medical Claims.
Home | Contact Us | Member Benefits | Search | Advertising | Member Area
 JOIN NOW
Become a member & get immediate access to all of our resources.
 SEARCH


Take a Free Tour
About ALO
 Who Should Join
 Download Samples
 Member Benefits
 Terms & Privacy Policy
 Take a Tour
 Member Comments
 Frequently Asked Qs
 Advertising
Discussion Forum
 MEMBER RESOURCES
 Appeal Letters
 Audio Conferences
 Discussion Forum
 Download Library
 Articles & Case Studies
 State Resources
 My Membership
 Virtual Exhibit Hall
 Help
 APPEAL TOPICS
 Providers' Rights
 Benefit Disclosure
 Utilization Management
 Medical Necessity
 Incorrect Payments
 Prompt Pay
 Treatment Excl/Limits
 Refund & Recoupments
 Specialty Care
 ERISA
 Medicare
 Contract Negotiation
 Other Topics
Visit our Online Store.
 Forum Topics
• Horizon BCBS
• EXPERIMENTAL INVESTIGATIONAL
• Humana denying nail debridements when other services rendere
• UBH MNRP - SUBSTANCE ABUSE REV CODES
• UBH substance abuse denial due to rendering provider issue
• Ambulatory Surgery Center Start Date
• Denial based on facility Accrediation in CA
• AUTOMATIC RECOUPMENT-HEALTHPLUS AMERIGROUP
• LA CARE DENIALS
• Medicare denial - referring MD not eligible to refer for ser
• Federal BC pay provider
• Pay the member
• GEHA - DENIED NOT MEDICALY NEC.
• aetna denying anesthesia
• Align Networks
Home | Medical Necessity



Appeal Topics
Medical Necessity

Medical necessity appeals shape healthcare. Uncontested medical necessity denials result in a subtle shift in treatment availability to the next patient because insurance carriers aim to consistently apply medical necessity limitations. Effective medical necessity appeals, on the other hand, bring to the carrier’s attention necessary variations in care, emerging efficacy issues, and situations that reveal flaws in the day-to-day clinical application of the carrier’s written criteria. For this reason, quality appeal review is critical to each of us. Appeal Solutions has detailed tools for improving medical necessity appeals.


Topic Areas for Medical Necessity:

Medical Necessity: An Ill-Defined Term
Medical necessity is a term which has different meaning to different health care participants. Understanding the carrier’s definition is helpful in drafting appeals. . . .more >>

What Goes Wrong With Medical Necessity Review
A number of shortcomings have been identified with medical necessity reviews. Be on the alert for the common procedural shortcomings which can indicate a poor medical necessity review process. . . .more >>

Medical Necessity Appeal Component 1: Summarize the Patient’s Care
The cornerstone of your appeal will be developing a compelling clinical argument for the care and referencing published clinical care guidelines. . . .more >>

Medical Necessity Appeal Component 2: Cite Regulatory and/or Compliance Information
Clinical arguments are often not sufficient to overturn an adverse determination. Your appeal must also cite potentially applicable regulatory and/or compliance issues in order to assure a quality review process. . . .more >>

Medical Necessity Appeal Component 3: Demand Disclosure of Payer’s Denial Basis
Payers rarely fulfill the obligation to fully disclose the basis of medical necessity denials. Reviewer's credentials, clinical review criteria and even date of development of clinical criteria should all be sought from the carrier to allow you to fully assess a denial's conformity to industry standards and regulations related to appeal review. . . .more >>

ERISA Medical Necessity Decisions
ERISA, the federal law which governs most employer-sponsored group health plans, has a number of protections directly related to appeal review. Among the most important to medical necessity appeals, ERISA requires expert review of any denial involving medical judgment. Unfortunately, while carriers often extend expert review to patient appeals, provider appeals often do not automatically garner a high quality, expert review process. . . .more >>