What does medical necessity mean?

We depend on our doctors and healthcare providers to recommend whatever diagnostic measures, medications, procedures, or services are required to maintain or restore our health. The order of a physician or other healthcare provider may not be enough, however, to ensure your health plan will cover the costs of a specific treatment regimen or service. 

For a recommended procedure, medication, treatment, or service to be covered by your health plan, it must be ordered by a physician or other healthcare provider and considered a medical necessity. 

What does ‘medical necessity’ mean?

The Medicare program’s glossary defines ‘medical necessity’ as follows:

Healthcare services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine. – Medicare.gov

Your healthcare plan must designate a service, treatment, procedure, or medication as a medical necessity before it covers any part, or all, of the cost involved. 

Why isn’t It covered?

Blue Cross and Blue Shield of Kansas has its own process for determining what treatments, tests, medications and services are covered under the plan. While your physician or other healthcare providers may decide a procedure, test, or medication is medically necessary, it may or may not be designated a covered benefit under your Blue Cross and Blue Shield of Kansas plan. 

‘Covered benefits’ are those that your health plan or policy has agreed to cover, and an order by a physician or other healthcare providers for a particular service, prescription, treatment, test, or therapy recommendation doesn’t trigger an automatic payment as a covered benefit under your Blue Cross and Blue Shield of Kansas policy. BCBSKS has a detailed process in place to help determine which services, drugs, tests, etc., are covered by its policies.

Importance of the process

The process used to determine what falls under the coverage of your Blue Cross and Blue Shield of Kansas policy provides a set of guidelines that make quality care the top priority while also keeping costs under control. Without these rules that outline the medical procedures, services, devices and drugs that are eligible for coverage, or excluded from coverage, the costs for services used by you, your family and your co-workers would be passed on through increases in premiums, high deductibles, increased copayments and more costly coinsurance. To maintain affordability in these areas, healthcare coverage must include some restrictions.

Variations in coverage

Every health insurer will have its own process for determining coverage eligibility. This will be based on the insurer’s own set of medical policies. Blue Cross and Blue Shield of Kansas, like most insurance companies, has its own set of detailed rules it uses to determine what services it covers. BCBSKS covers supplies and services that are necessary to diagnose and treat your medical conditions. These services and supplies must meet accepted standards of medical practice to be covered. 

There are some benefits that the federal government mandates all insurers provide. Under the Affordable Care Act (ACA), for example, services that health insurance plans must cover include doctors’ services, inpatient and outpatient hospital care and prescription drug coverage. 

In all, there are ten categories of services that are mandated under the ACA. Some plans cover more services than others. Specific services will vary based on the requirements of individual states.

Non-covered services

Blue Cross and Blue Shield of Kansas includes some specific restrictions, such as types of cosmetic surgery, while some non-covered restrictions are more general, such as over-the-counter drugs. Plans usually exclude emerging experimental treatments and technologies from coverage. 

Decisions concerning coverage vs. non-coverage are based on clinical evidence established and documented by healthcare associations, medical societies, academic medical research centers, and the Blue Cross and Blue Shield Association. Regional and local trends and guidelines help to establish the medical policies of Blue Cross and Blue Shield of Kansas. In keeping with our determination to keep our policyholders informed of decisions and changes in policies impacting healthcare coverage, over 200 medical policies are accessible through our website.

When simplicity is the best option

Healthcare is a complex, complicated field with a massive number of rules, regulations and constantly moving parts. There is one basic principle that’s easy for everyone to grasp: The more paid out in claims, the more premium dollars will be needed to replace them. The team at Blue Cross and Blue Shield of Kansas is dedicated to the goal of keeping premium costs affordable and manageable for all our members. 

Keeping premiums, deductibles and copays under control can be challenging. Often a less expensive treatment or procedure is available and offers more successful outcomes. In some cases, simple changes in lifestyle can lead to better health outcomes than expensive, invasive surgeries. 

Appeal a denied claim, service or procedure

If you disagree with a decision by Blue Cross and Blue Shield of Kansas that denies payment of a claim or refuses coverage for a service or procedure ordered by your physician or healthcare provider, you have the right to appeal that decision. As a Blue Cross and Blue Shield of Kansas member, you have the right to lodge a complaint against claims or coverage denials. It is your right to receive an answer to your complaint within a reasonable period of time. You can appeal any adverse benefit decisions and have the right to receive copies of the documentation used in making the decision to which you object. 

Knowledge is power

The best way to get the most out of your insurance plan is to take the time to learn about your coverage parameters. If you learn how your health plan works and how to best use it, you can avoid many of the headaches that can come from difficulties with your coverage.

Take the time to learn what your insurance plan will pay for, and won’t pay for, before you have a procedure done, take advantage of a service, get testing done, or even fill a prescription. If you find yourself questioning the scope of your health plan’s coverage, you can make a call to a Blue Cross and Blue Shield of Kansas representative who will work with you to answer any question you have.

Leave a Reply