Use Health Plan Policies to Avoid Denied Claims

Coverage policy, medical policy, clinical policy, reimbursement policy … health plans’ policies are the guidelines they use to help decide what services and procedures they consider medically necessary and how they will — or will not — pay for them.

The various policies are tools you can use to help determine if the treatment you believe a patient needs will meet the health plan’s criteria for medical necessity, how a patient’s health benefits will apply, and how you can potentially avoid denied claims. Note the following:

  1. Actual coverage may vary among a payer’s different insurance products (i.e., among HMO, PPO, EPO, and Medicare/Medicaid plans). Always check your patient’s specific benefit policy even when a health plan has relevant policy on its website. When possible, get the coverage information in writing from the health plan.
  2. Don’t assume a health plan doesn’t have a policy because you don’t see one that’s obviously named on its website. Health plans have different names for the same policy. For example, if you were looking for policy on allergy immunotherapy, you’d find what you need here:
  1. Make sure you know how to access policies easily. For example:

            Some policies are online in the payer’s secure provider portal; register for payers’ portals so you have access to this
            and other information and features. 

  1. Use the health plan bundling edits and cost estimator programs to help determine a patient’s potential financial responsibility. They also can help steer you toward policies specific to the CPT codes you enter in the programs.
  1. If you need help locating a payer’s policy, contact TMA’s Payment Advocacy specialists at paymentadvocacy[at]texmed[dot]org or (800) 880-7955. They can help when they have access to a particular payers’ policies. 

 Published June 28, 2017

TMA Practice E-Tips main page

Last Updated On

April 19, 2018

Originally Published On

June 28, 2017