It may seem like a fairly obvious description however many patients and doctors don’t know what this phrase means. Simply put it is a procedure that is not covered by the patient’s insurance plan. Most providers are confused because it is assumed that if a patient meets medical necessity then the medical plan will pay for the services. Not true. Medical plans, much like dental plans, have services that can be excluded from their covered services list.
The reasons for exclusions vary. It could be that the state the patient is located in does not require the service to be covered under insurance plans. It is possible that the employer chose a plan that excludes certain services to reduce premium costs. Or that services are just of a nature that industry-wide they are not commonly a covered item yet.
It is of paramount importance to check your patient’s benefits before estimating any coverage to make sure all of the procedures you will be doing are covered services. If they are non-covered services the patient will be solely responsible for the fee. Non-covered services are also included in the member’s coverage booklet which they receive when their coverage starts. They can always reference this to know if procedures may be eligible.
When services are denied as being non-covered or excluded an appeal typically will not change that decision. If you did obtain benefits, either via telephone and have a reference number or by fax, you can file an appeal that services were delivered in good faith expecting coverage. Many policies will review this and, if necessary, pull the phone call to check. Most of the time these decisions will be given a courtesy reversal since the patient had good faith that the insurance would cover a portion of the procedures and would not have otherwise pursued such expensive treatment. It is not a guarantee though. It is always best to spend the time to verify what is and isn’t eligible under the patient’s plan to prevent errors in treatment planning and collections.
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