Insurance Coverage – Artificial Discs
Medical insurance helps you get the treatment you need. But there are times when your insurance provider might not agree with your doctor's recommendation. Knowing how to communicate effectively with your insurance company can be the first step toward a successful claim resolution.
Your health insurance policy is a contractual arrangement between you and your insurance company. Your policy will list the services that are covered and those that are not. Both you and your insurance company are bound by the terms of the agreement.
The way your relationship with your insurance company should work is:
- Your doctor recommends a treatment or surgery.
- You or your doctor file the paperwork to get medical services pre-certified with your insurance company.
- An insurance company representative notifies you or your doctor that the treatment is covered.
- You undergo the treatment or procedure and your insurance company pays for it, less any co-pay or deductible.
Sometimes, your insurance company may not be willing to provide coverage for a treatment or surgery. Possible reasons include:
- The treatment or surgery is specifically not covered under the terms of your policy.
- You have exceeded your benefit level.
- The treatment may be covered, but with restrictions. For example, you may be required to go to a doctor within your insurance provider's physician network. Or, the treatment may be covered, but only for a specific diagnosis.
- Your doctor is recommending treatment that involves new technology that your insurance company considers experimental or investigational.
- Your insurance company has determined the treatment is not medically necessary.
Insurance companies are required to provide their covered members with a process for reconsideration and review of any adverse decision or claim denials. They also must provide information about this review process.
By providing the right information according to the insurance company's policies and procedures, policy holders are often able to overturn a claim denial.
If you decide to appeal, you will need to communicate clearly your reason(s) for doing so and be able to produce documentation to support your claim. This might include a Letter of Appeal (from you or your doctor) and a Letter of Medical Necessity (from your doctor), and any other paperwork your insurance company may require.
In instances where new technology is an issue, you may want to include copies of peer-reviewed journals and clinical outcomes data regarding the treatment that has been denied coverage.
Information on this site should not be used as a substitute for talking with your doctor. Always talk with your doctor about diagnosis and treatment information.
Last updated: 3 Aug 2008
