Who Defines Medical Necessity?
All third party-payers, including Medicare, get to decide what type of chiropractic care they will actually pay for and what the definition of medical necessity is for their insured. Below you will see a couple of examples of medical necessity definitions for chiropractic care. Medicare is very straight-forward in its description of medical necessity in a chiropractic office, other carriers are not as helpful.
Medicare’s Medical Necessity Definition:
“The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.”
Aetna Shares About Medical Necessity:
Some plans have limitations or exclusions applicable to chiropractic care. Please check benefit plan descriptions for details.
My Chiropractic Claims Just Got Denied for Medical Necessity. Now What?
Make sure the care you rendered met the stated medical necessity definition of the third-party payer. Also, verify your chiropractic documentation contains all the required details to prove their definition of medical necessity was met. Begin the appeals process to get your chiropractic claim properly adjudicated.
I want to thank you for your expertise and time spent educating and assisting our company, Harmony Healthcare, Ltd. with regards to becoming more HIPAA compliant so that we can better serve our clientele. In our current times, the safety and protection of personal information is of high importance and concern and we are blessed to have KMC be our expert guide. We appreciate you and your team!