Why Medical Necessity Is Important

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Explain why medical necessity is important: “Medically necessary” is a term used by health insurance companies. It is included in the benefit book to describe services (treatments, tests or drugs) from doctors. Generally, “medically necessary” includes all of the following four parts: 1. Most doctors agree that the treatment is useful and helps people. They use the treatment for their patients. The treatment is taught in medical schools. Doctors recognized as experts by other doctors recommend the service. 2. Most doctors say this is the right or best treatment for a specific disease or problem. Medical schools and experts agree that this is a good treatment for the problem. 3. The service is not just for the convenience of the doctor, the patient or the family. 4. The service does not cost far more than a treatment that is just as likely to work for the problem. “Medically necessary” does not mean that a doctor recommended the treatment. It is a term that all health insurers use, and has a special meaning listed in your benefit book. Medically necessary treatments have to meet all of the points above to be covered by the plan. Explain code linkage: Medical codes are assigned to procedures and diagnoses to bill insurance companies for the services doctors and other health care workers provide to patients. Diagnosis codes must be correctly linked to procedures to establish medical necessity. Explain what medical billing and coding is: When a patient has any medical exam or
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