Convince Your Insurer the Surgery is Medically Necessary
If someone tells your insurer that the surgery is necessary, then the insurer will agree, right? No.
As backwards as it seems, and whether it is legally or morally right or wrong, it is your insurer and not your medical professional who decides what is "medically necessary" for you. So how do you and your doctor convince the insurer? Ideally, you and your surgeon need to find out how your particular insurer makes the determination of medical necessity. In other words, its criteria for coverage.
In order to do this you need to write your insurer and ask. Insurers can be notoriously secretive and reluctant to answer such requests, so if they don’t reply, write again, documenting the fact that you and your surgeon haven’t received information you both consider vital to properly processing your claim.
In a best case scenario, your insurer tells you its criteria, which you respond to item-by-item in your request for pre-authorization.
But what if your insurer never replies? Don’t worry. If you include all of the information we outline in the surgeon’s Pre-Authorization Letter, you will have provided at least the basic information your insurer will need.
*TRICARE patients require a referral of the army doctor and a CHAMPUS CLAIM FORM.
Copyright 2005
Professor Rudolf Weiner, MD
About Us / Contact Us
|
Terms of Use & Privacy
Policy |
by OBGYN.net