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  • Writer's pictureMuhammad Sair Khan

How to Prove Medical Necessity to Reverse a Claim Denial

Medical necessity is one of the most common reasons that insurers deny behavioral health claims. It is possible to get this type of denial overturned, but to do so; there are a few essential steps to follow.

What is Medical Necessity?

The first thing you should familiarize yourself with is what criteria payors use to determine medical necessity. By definition, medical necessity is any health care service that is needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms. To make this determination, claim adjusters consider the following:

  1. Are the services based on credible, scientific evidence recognized by the medical community?

  2. Are the services clinically appropriate regarding type, frequency, and duration?

  3. Is the service effective for the illness it is treating and not more costly than an alternative service?

This criteria is subjective, and even if the treatment is pre-authorized, the insurance claim can still deny. This is why it is critical to keep thorough clinical notes and record of the patient’s experience throughout his or her time at the facility. How to Appeal

Before you write an appeal letter, gather all of the information you have on the client. Review the diagnosis, the treatment plan and authorization number that you agreed upon with the case manager, and any clinical notes you have during treatment.

Familiarize yourself with the appeal process for the insurance company that you are submitting the appeal to. You will also benefit from reviewing the patient’s specific policy, verifying there are not any written provisions that you may have missed during the VOB. Writing the Appeal

Once you are familiar with the appeal process and gather all of the information to support your case, you are ready to write an appeal. Your letter should be clear and concise, citing specific, evidence-based reasoning as to why the insurer should reconsider the claim. We recommend following ASAM criteria guidelines for the level of care you billed. Include the prior-authorization number (if applicable) and any relevant notes from prior conversations with insurance representatives.

At the top of the letter, include the client’s name, policy identification number, and the claim number that you are appealing. List the name of your facility and the NPI or Tax ID number. Attach any clinical notes and send the appeal using certified mail, fax or per the insurer's guidelines.

For more information on this topic and much more, view our Behavioral Health Guide to Quick and Accurate Claims Processing. You can also download the PDF format by clicking on the image below.

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