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Treatment Exclusions & Limitations
Treatment Exclusions and Limitations have a direct impact on provider reimbursement. Unfortunately, denials related to policy or plan exclusions and limitations are often not appealed because providers do not have sufficient information regarding the policy or plan terms. We provide information on how to approach these types of appeals under the following Treatment Exclusions and Limitations Topic Pages.
Topic Areas for Treatment Exclusions & Limitations:
Coverage Termination
Consolidated Omnibus Budget Reconciliation Act (COBRA) gives certain workers the right to continue group health benefits through a previous employer. Every claim due to lack of coverage should be checked for potential COBRA coverage. . . .more >>
Experimental Treatment Appeals
Access to new drugs, procedures and equipment is one of the most challenging aspects of healthcare delivery. Patient are rarely in a position to aggressively appeal for access. However, medical organizations can approach such appeals thoroughly using these suggestions and letters. . . .more >>
Maximum Benefit Appeals
An effective maximum benefit appeal should demand an audit of benefits released to date. The purpose of the appeal is to determine to dollar amount of benefits released and to whom the previous benefits were paid to determine if the benefits were exhausted. . . .more >>
Preexisting Conditions
Preexisting decisions rest of determining the onset of a medical conditions. See our letters which can assist with appeals meant to clarify the inception date or disclosure of the exact treatment received prior to coverage. We also have letters which assist with appealing for compliance with laws requiring carriers to credit patients for previous coverage. . . .more >>
Timely Filing Limitations
A successful timely filing appeal often involves submitting proof of timely filing. Read how to use an affidavit to strengthen your timely filing appeal. . . .more >>
Treatment Caps
Treatment caps appeals require the submission of detailed medical documentation. Often, care beyond a set number of visits can be obtained but it requires an explanation from the provider. . . .more >>
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