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What if your care is not deemed to be medically necessary?

Many in Rockingham County may mistakenly believe that the only those who do not have health insurance struggle with medical debt. However, having insurance may not always be a guarantee of coverage. If you are suffering from health problems that have required you to seek medical treatment, then you may know well how costly such services can be. However, you could potentially experience even greater surprise than how quickly medical debt can accrue if you were later to find out that your insurance claim was denied.

Oftentimes, the reason for your denial is because the services that you received were not deemed to be medically necessary by your insurer. While the definition of medical necessity may differ slightly between the various insurance companies, the general meaning of most may be similar to that of Medicare, which defines “medically necessary” as “Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.” Based off of this definition, it may be easy to understand why cosmetic procedures or non-emergent drugs like acne or weight loss medication may not be deemed medically necessary.

Yet what about hospital care needed to prolong or save your life? Should these services be denied for not meeting medical necessity, there may a good chance that errors existed on your original claim. Medical necessity is often determined off of the diagnosis given by your doctor. If the diagnosis codes on your claim were incorrect, submitting an amended claim might be all that is needed.

In certain cases, your services may be denied because the treatment or medication you received is considered experimental. If this happens, you might want to consider disputing the claim with the support of the provider who rendered your care. 

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