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Insurance Denials and Next Steps

You’re being referred to get additional testing or procedures. What happens now?

We will submit the request to your insurance company for authorization/ approval. Your insurance company has guidelines and requirements set forth that need to be met in order to approve certain tests or procedures.

Once we submit the request, your insurance company has up to 15 business days to review the request and make a determination.

What happens if your insurance denies the test or procedure?

Your insurance company will give us a reason as to why they denied the test/procedure. Based on the information provided, we will decide next course of action for you and your condition.

If the insurance company denied the request because you did not have conservative treatment:

  • We will ask your doctor to initiate conservative treatment (Physical therapy, OTC medications, home exercise programs, etc.)
  • You will need to do this for a minimum of 6 weeks
  • When you have completed the 6-week conservative treatment plan, you will follow up with your provider so we can submit a new note to your insurance company (we hope this will overturn the denial).

If the insurance company denied the request because it is excluded from your plan:

  • There are limited options with this scenario. Sometimes treatment is excluded from your insurance because the insurance company does not view it as a medically necessary treatment (even though your doctor is recommending it). NOI offers cash discount pricing if you would like to proceed with the treatment.
  • We will ask your provider if there are alternative treatment options available that would be approved by your insurance provider for your specific condition.

If the insurance company denied the request because you did not meet all of the criteria:

  • If this option occurs, and the physician feels it is your only option or your best option, we will try a peer-to-peer consultation between your NOI physician and your insurance company to discuss your condition and treatment options in hopes of approving the procedure.

What happens if the insurance company wants an appeal filed for your procedure?

Our office can help walk you through the process. Generally, the insurance company is asking for the patient to submit an appeal to the denied procedure. This is not allowed in every case. You must have met all of the criteria set forth by your insurance company in order to go down this route.

If you have any questions, please feel free to reach out to our office staff at (949) 722- 7038 for further help with questions.