Network adequacy/access to specialist standards are designed to make sure that health plans have an adequate network of providers within a specific geographic area and sufficient specialty care providers to provide quality care. These regulations often specify the types and number of primary care and specialty providers necessary, the distance enrollees have to travel to see their providers, and the hours of operation and processes for requesting out-of-network care if the care is not readily available.
Although these protections affect the design of the network, they can also be cited in situations in which it appears that care was rendered out-of-network due to the unavailability of network care. Such protections may be valuable in situations in which a carrier provides a hospital precertification but does not include ancillary or specialty care services within that precertification.
In particular, hospital specialists such as pulmonologists, radiologists and ancillary providers such as physical and occupational therapists should actively appeal out of network benefit reductions in situations were innetwork care was not readily available to the patient.
Such appeals should summarize the patient’s care and treatment and include any information on what steps were made to provide in network options. If a hospital obtained a blanket authorization for the treatment, your appeal can request that the authorization include any treatment arranged by the attending physician. Use wording such as the following:
“It is our understanding benefits have been reduced due to out of network exclusions or limitations. As you are likely aware, many states have network adequacy laws to insurance that managed care participants have ongoing access to quality care. It is our position that additional benefits should be allowed due to patient’s inability to access readily available innetwork comparable services. Further, precertification was obtained by (insert hospital name) and this precertification should extend to all medical services necessary to assure the safety and complete recovery of the patient. If additional benefits are not allowed, please provide a description of the comparable innetwork medical services available at the time of this treatment.”
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