Policy Statement
Our health plan will deny reimbursement for claims associated with denied services including: investigational, cosmetic, not medically necessary services, non-covered items and services, and contract exclusions. This applies to all services and claim types. In addition, we will not allow providers or members to retain reimbursement from us for these associated claims. Responsibility for the costs associated with these claims will be assigned to the provider or member depending on the denial type.
Some examples of services that may be denied as associated claims include, but are not limited to, services provided or performed:
- By the provider or associate performing the denied service
- By the provider without the required preauthorization.
- By any provider billing evaluation and management (E&M) related services
- By any assistant surgeon
- By any anesthesia provider
- By any pathology provider
- By any radiology provider
- By the facility where the service was performed
- At the same time or during the same operative session (regardless of whether the service was billed)
- Prior to or subsequent to an initial related denied service
In the case of equipment that is not covered, related services would include, but are not limited to:
- Supplies
- Batteries
- Replacement equipment
- Set-up fees
References
Cross References
