HNS Policy 

 

Contracted health care professionals shall only submit claims to HNS for services which are medically necessary, and which are consistent with HNS Policies and the policies of contracted payors. (Exception: maintenance/wellness care)

 

The clinical record must include documentation which objectively substantiates the medical necessity of the covered services billed to payors.

 

Medically necessary care must be evidenced by all relevant standards included in HNS' Clinical Quality & Documentation Standards.

 

The following are considered essential "core" standards to help improve treatment outcomes and to help ensure only medically necessary care is billed to contracted payors.

 

  1. Establish and document the patient's chief complaint.

  2. Based on the chief complaint and clinical exam findings, establish specific treatment goals for each patient which are objectivemeasurablereasonable, and intended to improve a functional deficit.

  3. Ensure your initial examination includes the use of standardized outcome assessment tools to establish a functional baseline against which progress towards treatment goals can be objectively measured.

  4. Re-evaluate the patient every 4 weeks or 12 visits (whichever comes first).

  5. Always use outcome assessment tools and other objective measures at each re-exam, to measure progress toward treatment goals, the effectiveness of treatment, and the appropriateness of additional care.

  6. Use the comparison of the results of the outcome assessments, and other measurable objective findings, to determine when MMI has been reached, then release the patient to maintenance/supportive care.

  7. Ensure all diagnoses, all services provided, the rationale for those services, and all treatment recommendations are properly documented in the health care record.

  8. Ensure that all treatment billed to payors is consistent with the chief complaint, objective clinical findings, diagnoses, and payor corporate medical policies. 

 

 

(The HNS Clinical Quality & Documentation Standards are posted on the HNS website.)

 

All medically necessary care provided to patients whose health care plans contract with HNS must be billed through HNS, UNLESS the patient signed, prior to the beginning of care, one of the HNS Election Not to File Forms, and the form is on file in the patient's health care record.

 

It is important to remember that clinically appropriate care does not always meed the definition of medically necessary care, as defined by payor corporate medical policies.  While physicians should always provide clinically appropriate care to their patients, not all clinically appropriate care is covered under a member's health care plan, and only benefits covered under a member's health care plan should be billed to the payor.

 

Repayment to Payors

 

HNS Policy:

Providers shall not retain fees to which they are not entitled. If a provider receives payment for services which a payor determines are not medically necessary, the provider shall timely repay those monies to HNS, or to the payor, and shall do so in the manner and form specified by HNS or the payor.  This policy survives the termination of the HNS Practitioner's Participation Agreement.