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Asking Insurers to Deviate from Medical Necessity Clinical Guidelines
Insurance carriers routinely cite evidence-based clinical
guidelines when denying treatment authorization. However, a number of insurance
industry resources confirm that insurance medical decision makers must consider
the patient’s unique medical condition and should deviate from the clinical
guidelines when appropriate. Requesting deviation from the guidelines will
typically require an appeal focusing on the patient’s unique medical needs and
why application of the guideline is not appropriate....Read this entire article
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Medical
Necessity Audioconference:
Train your entire staff on tactics for selecting and preparing
the right appeal letter for different types of medical necessity denials.
This conference will be held March 27th. Registration is limited.
Call 888-399-4925 or
Click
here for more details |
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AppealLettersOnline Featured Letters
We have added appeal letters to assist subscribers with obtaining the clinical or
evidence-based review guidelines used by the insurer to assess medical necessity. See the Topic Medical Necessity and Subcategory
State Medical Necessity Terms for the following letters:
1. Request for Clinical Review Criteria
2. Florida Request for Clinical Review Criteria
3. New York Request for Clinical Review Criteria
4. Texas Request for Clinical Review Criteria
We have also added a letter (Acuity of Care Appeal) to assist subscribers with requesting a deviation from the clinical care guidelines based on
patient-specific issues. Sign up to access these appeal letters |
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Attachment of Medical Records to Medical Necessity Appeals
Medical Records must
be attached to emergency care, experimental/investigational, medical necessity
and prior authorization appeals as well as many coding appeals. Lengthy medical records should be reviewed
and pertinent information highlighted and marked with a page marker to ensure
that the appeal reviewer sees the pertinent information. A summary of the
clinical justification for treatment should appear within the body of the
appeal letter but is typically not sufficient documentation for the insurance
carrier. The medical records’ history and physical is also a good source of
information on other providers who have seen the patient and may have medical
records establishing failure of less aggressive treatment and the patient’s treatment
resistance justifying more aggressive care. Previous treatment provider
references should be highlighted in the medical records so that your appeal
letter can instruct the insurance carrier to obtain all pertinent medical
records related to the review.
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