Medical necessity - what is it?

Insurance companies have guidelines that may limit coverage based on the diagnosis or frequency of a service (how often the service is performed).

In Medicare terms, “not medically necessary” means that the service is not a benefit for the diagnosis or at this frequency.  Your treating provider can discuss why this service is medically indicated for you, but Medicare does not consider it medically necessary.

What is an ABN (Advanced Beneficiary Notice) form?

https://www.medicare.gov/claims-and-appeals/medicare-rights/abn/advance-notice-of-noncoverage.html

The ABN form indicates that Medicare will probably deny payment for the service and tells you the reason.

It will tell you the estimated cost of the service which you will need to pay.

It allows you the opportunity to accept or refuse the service and protects you from unexpected expenses if Medicare denies payment.

It also offers you the right to appeal Medicare’s decision

But I’ve had this test in the past – what’s changed?

In order to ensure that we’re compliant with Medicare rules, this is a new
policy at Adirondack Health.

How do I contact Medicare to ask questions about my coverage?

Medicare has a website: www.medicare.gov

Medicare toll-free phone number: 800.633.422

What is a Notice of Financial Responsibility?

A Notice of Financial Responsibility indicates that your insurance company will deny payment for the service and tell you the reason.

It will tell you the estimated cost of the service which you will need to pay.

It allows you the opportunity to accept or refuse the service and protects you from unexpected expenses if your insurance company denies payment.