Scope of Practice Appeals

Many healthcare providers, from advanced practice nurses to chiropractors, routinely receive denials due to the fact that the services and/or procedure performed is only covered when provided by a licensed medical doctor. These denials can often be successfully contested by citing state scope of practice information if the provider is acting within the scope of the applicable medical license.
Scope of practice appeals should also demand that the carrier release the exact policy or plan limitation or exclusion which supports the denial. Here is a sample of a well worded demand for scope of practice denial information:

The above referenced claim was denied due to no benefits allowable for (insert service or procedure description) when performed by a licensed (insert provider type). The explanation of benefits did not give adequate information regarding the specific policy or plan exclusion which supports the denial. As you are likely aware, policy and plan benefits are often allowed as long as the healthcare provider is acting with the scope of state healthcare licensing laws and the procedure and/or service is a covered benefit. To disallow benefits to providers acting within their scope of practice, the policy or plan must clearly set forth an applicable exclusion or limitation. Therefore, please provide the following information so that we may assess the accuracy of this decision:

1. A copy of the applicable policy or plan limitation related to (denied procedure or service) as it reads in the policy or plan description.
2. Any policy or plan wording related to (provider type) benefits and any related definitions.
3. Benefit information regarding (insert category of procedure or service, such as diagnostic tests, radiology, therapy and/or rehabilitation services) coverage.
4. A copy of any authorizations or verification of benefits extended to this patient related to this treatment.

This information is necessary to determine the accuracy of the denial and to determine the availability and applicability of benefits for this treatment. Please be advised, (procedure or service) is routinely provided by (provider type) in this state and this patient’s care has been coordinated with (insert referring or managing physician) when required. Thank you in advance for your prompt disclosure of the requested information above.