Some Health Plans Have “Source of Injury” Exclusions, With Limits

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) allows plans to deny coverage for members who get hurt while participating in recreational activities the plan considers dangerous, but not for injuries that result from a medical condition or an act of domestic violence.

HIPAA regulations in 29 CFR 2590.702(b)(2)(iii) allow plans to exclude coverage for an injury from a specified dangerous activity as long as the plan excludes coverage for all members injured that way and does not single out particular members. This is referred to as the “source of injury” exclusion. For example, a plan may cover head injuries but exclude head injuries sustained while an enrollee is participating in a plan-defined dangerous recreational activity, such as skydiving.

The rule that a plan may not deny benefits for treatment of an injury that results from a medical condition or an act of domestic violence was issued Dec. 13, 2006, under final HIPAA nondiscriminination regulations. This rule applies even when the medical condition was not diagnosed before the injury.

Say, for example, a plan covers head injuries and an enrollee suffered a head injury from a suicide attempt. If the patient attempted the suicide because he or she had an undiagnosed condition of depression, which is a medical condition, the plan would have to cover the injury.

To protect your practice:

  • Find out if the plans you contract with have source-of-injury exclusions (don’t rely on the plan to tell you unless you ask).
  • Review contracts. Check the definitions of “noncovered” service to ensure that the language is broad enough for you to bill the patient if your services are excluded from coverage by source of injury.
  • Update your verification process. Find out from the patient how the injury or illness occurred and be sure to document that in the patient’s record. When you verify coverage with the plan, check that treatment related to that activity is still covered.
  • Review patient financial forms. Make sure your patient financial forms let you bill and collect for these noncovered services.

Content reviewed: 8/14/2008

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