Step-by-step guides on fighting health insurance claim denials. Understand your EOB, learn the difference between prior authorization and medical necessity, and master the appeal process.
Quick Facts: Medical Necessity Denials Aspect Actionable Insight The Definition Services required to identify or treat an illness that meet standard clinical guidelines. The Reality Often used by insurers as a blanket excuse to deny expensive treatments or newer therapies. Key Weapon A detailed “Letter of Medical Necessity” (LMN) from your prescribing physician. Appeal Success…
Quick Facts: Anatomy of an EOB Term Clinical/Financial Meaning Billed Amount The “sticker price” sent by the provider. Often highly inflated. Allowed Amount The maximum amount the insurance will pay for a service based on their contract. Member Rate The discounted rate negotiated between your insurer and the hospital. Remark Codes Alphabetical codes explaining why…