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Want to know what coverage criteria an insurer requires before even getting on the phone with them? Good news is - most medical insurers will post their medical policies right on their website!
A medical policy is intended to provide guidelines and coverage criteria for:
- Services
- Equipment
- Technology
- Procedures
Examples of information you may find in a medical policy are:
- What services are covered, and not covered
- Coverage criteria to meet medical necessity
- CPT & HCPCS codes covered, and not covered by policy
- Diagnosis codes covered, and not covered by policy
- Additional billing/coding information – i.e. modifiers, appliance guidelines
- Definitions & Resource
- Example documentation
A medical policy is different that a patient’s coverage policy
- The medical policy is criteria and guidelines set by the insurer
- The patient’s coverage policy is what specific benefits that patient’s policy carries
To find the medical policy for the treatment you are looking for:
- Start with the insurer’s main website (or website on patient’s medical card if you have it!)
- Locate the “providers” section (you will generally also find “members”, “employers”, investors”, etc sections of the site)
- Locate the medical policies section (sometimes labeled “policies procedures & guidelines”, “practice resources”, “coverage policies”, “clinical policy bulletins” (CPB’s), local coverage determinations” (LCD’s)).
- Search for the subject you are treating! i.e. sleep apnea, temporomandibular disorders, pain, accident, oral surgery, etc
- If a policy is not available online, you can call the insurer to request a copy be faxed/mailed/e-mailed to you
Below is an example of language you may find in a medical policy (the example below is a policy related to oral appliances for obstructive sleep apnea):
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