medical necessity AND MMI

Services provided and billed through HNS should be delivered in the most 

effective and cost-efficient manner.  

To establish the medical necessity for services provided and billed to HNS payors, those services must be consistent with the HNS payor policies, the practice guides issued by the NC BOCE, and documented chief complaint and clinical findings, diagnoses and treatment plan.  Clinical examination findings must objectively substantiate the medical necessity of services provided and billed to HNS contracted payors.

Per the NC Board of Chiropractic Examiners Practice Guides:

"The physician should re-evaluate the appropriateness of further care after whichever comes first, approximately twelve office treatments or four weeks of care (i.e., one "treatment cycle").

If the patient shows improvement, the physician may recommend another treatment cycle.

For as long as improvement can be objectively demonstrated, the patient may continue treatment cycles.

However, if re-evaluation fails to demonstrate additional improvement after any two consecutive treatment cycles, the physician should assume that maximum therapeutic benefit has been reached.

Patients who have reached maximum therapeutic benefit may be candidates for supportive care, elective care, referral or release.

Once the goals of treatment have been realized, the patient may continue to need supportive care in order to prevent deterioration or relapse.

If a patient with an uncomplicated condition fails to show initial improvement after two treatment cycles, or a patient who initially showed improvement subsequently fails to show further improvement after one additional treatment cycle, the physician should assume that maximum therapeutic benefit has been achieved.

Patients who have reached maximum therapeutic benefit may be candidates for supportive care, elective care, referral or release."

Unless otherwise indicated by the payor, all services provided to a patient whose claims are submitted to HNS must be medically necessary and consistent with the patient’s chief complaint, clinical findings, diagnoses and treatment plan. 

All services provided and billed to a HNS contracted payor must be consistent with the policies of applicable state licensing boards as well as state and federal laws.

Please remember that clinically appropriate care does not always meet the definition of medically necessary care, as defined by the payor’s corporate medical policy.

Physicians should always provide appropriate care to their patients, however, 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.

The fact that a doctor may prescribe, order, recommend, or approve a service, procedure or supply does not, in and of itself, make it a covered service or medically necessary, even though it is not specifically listed as an exclusion.

For medically necessary services, payors may compare the cost-effectiveness of alternative services or supplies when determining which of the services or supplies will be covered.