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Understanding national and local coverage determinations

While the care that you can expect to receive from any of the hospitals and clinics in Jacksonville is among the best in the world, it may come at a step price. That may be why receiving a denial notice from your health insurance company can be so disheartening. One of the more common reasons why medical claims are denied is because insurers deem that the procedures performed were not medically necessary. Here at Tyler & Hamilton, P.A., we’ve had several clients come to us wondering if such a decision can be appealed.

The answer to that question may depend on your health insurance carrier. If you are covered by a government plan (Medicare and Medicaid), then coverage for your care is subject to national and local coverage determinations. Insurance providers try to avoid overpaying on claims by only covering those services believed to be reasonable and necessary. According to the Journal of Oncology practice, NCDs and LCDs are established to inform providers when services are deemed to be warranted. NCDs apply on a national scale, while LCDs pertain to certain regions covered by contracted Medicare administrators. Commercial insurance carriers will often mirror their coverage determinations to government plans, as well.

NCDs and LCDs themselves are guidelines that state the reason behind the determination, and the scenarios in which a service will be reimbursed. Those scenarios are typically conveyed by the diagnosis codes that a provider assigns to a patient encounter. Thus, if you receive a statement saying that your services were not medically necessary, you can ask the provider to review your encounter’s diagnosis coding in comparison to the listed NCD or LCD. If it can be amended, you can then have your claim reprocessed.

You can learn more about appealing insurance decisions by continuing to explore our site.   

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