Preventing Los Angeles Anthem Medical Necessity Denials

Under a majority of health insurance plans, health insurance carriers such as Anthem are required to pay for treatment that is considered medically necessary. However, determining what constitutes a medical necessity is a complicated process.

Whether a proposed medication, procedure, or course of treatment is a medical necessity entails an insurance company assessing an individual, rather than making a general determination. They must look at each claim to determine whether the procedure is necessary to prevent illness or disability, to alleviate pain, or to save a person’s life.

Unfortunately, health insurance companies often vary on what they consider a medical necessity. This allows health insurers to make subjective rather than objective determinations. However, there are steps you can take towards preventing Los Angeles Anthem medical necessity denials. A skilled health insurance denial attorney can work with you to make sure that you get the coverage you need for your medical procedures.

Preventing Medical Necessity Denials in Los Angeles

There is no exact answer or formula to prevent a denial based on a lack of medical necessity. This is because each insurance company has its own internal standards and criteria to determine whether a procedure is needed. The law clearly allows insurance companies, such as Anthem to determine whether a service is medically necessary.

However, the insurance company must make their decision in an objective way based on identifiable and discernable standards. When they fail to do this they are denying a claim in bad faith.

What to Do When Filing an Anthem Claim

While there is no absolute way of preventing a denial, there are steps policyholders can take towards preventing Los Angeles Anthem medical necessity denials. One way is to request and review a copy of the policy. By requesting a copy and reviewing Anthem’s policy under which it denied coverage, an insured can ensure that their intended procedure is covered.

One of the most effective ways of ensuring that a medical claim is not denied because of a lack of medical necessity is for a policyholder to bring a copy of the specific policy pursuant to which the insurer denied coverage to the providing doctor. Physicians commonly work with several health insurance companies on a daily basis and can help determine what a specific policy would cover or can help prove medical necessity.

A person can also reach out directly to the insurance company. If there is a concern that a course of treatment or procedure will not be covered, a person can speak with a customer service representative from Anthem who can clarify the policy before a request is made.

Finally, collecting documentation is crucial. Insurance companies will often deny a request because of a lack of documentation. This can be a problem for people with ongoing medical concerns such as diabetes. However, if a person is able to provide Anthem with documentation of their condition and the required treatment, they may be able to prevent a denial.

Contacting a Los Angeles Attorney to Discuss Preventing Anthem Medical Necessity Denials

As one of the largest health insurance providers in the Los Angeles region, Anthem has a responsibility to review each and every claim with care and diligence. Sadly, they wrongly deny many claims because of an alleged lack of medical necessity. However, a Los Angeles health insurance lawyer can help you take proactive steps towards preventing Los Angeles Anthem medical necessity denials.

Additionally, if you or a loved one have had a claim denied for lack of medical necessity, a dedicated health insurance lawyer can help guide you through the appeals process. Call today to learn more.