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What does "Medical Necessity"
mean to me? |
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If you choose to use
your insurance for your visits, you should know that Managed Care
Organizations (MCOs) are asked by insurance companies to distinguish between
"medically necessary," and "growth-oriented" therapy. Insurance will
pay only for those sessions determined to be medically necessary even
if you have more sessions left in your benefits for that year.
Your contract with your insurance company provides that all mental
health providers are required to provide the insurance/managed care
organization with clinical information and access to your records if
there is a question regarding medical necessity.
"Self-pay" (versus
insurance-reimbursed) sessions beyond those authorized as medically
necessary can be arranged by speaking to me if you desire to continue
for growth-oriented therapy after your authorized sessions are used.
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Self-Pay vs.
Insurance |
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I have a mixture of
self-pay and insurance-reimbursed clients. Some clients prefer
the anonymity associated with receiving care outside of the health
insurance system. The decision of whether or not to use
insurance has no bearing on the care you will receive.
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Covered Insurance Plans |
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If you are
planning on utilizing your insurance, you should first check with your insurance
company to see if they require you to get an authorization for
your sessions. |
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If so, write down the
name of the person you spoke with along with the authorization number,
the time and date of your call, and the number of sessions authorized.
The authorization will also have a start date and an end date.
You may also verify
your deductible (if applicable), your co-payment, and/or patient
responsibility at this time. Some plans, such as Guardian / PHCS,
often have a "co-insurance" portion
in addition to the co-pay. You will need to bring this information
with you to your first appointment.
I am
a provider for each of the plans listed below. Please contact your
insurance carrier/managed care organization directly to confirm
whether Dr. McGarry is a covered provider for your plan.
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Aetna |
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Blue Cross-Blue
Shield PPO, FEP |
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Cigna PPO & HMO |
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Cigna Behavioral
Health |
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Magellan Behavioral Health |
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GreenSpring / MBC |
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Medicare |
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Mental Health Network (MHNet PPO
Only) |
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OptumHealth Behavioral Solutions (Formerly UBH) |
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PHCS Private
Healthcare Systems PPO & MHSP |
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Preferred Plan of Georgia |
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Principal PPO &
HMO / Southcare |
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Value Options |
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Wellcare
Behavioral Health |
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Wellpoint Behavioral
Healthcare |
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Types of Insurance |
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The array of
insurance plans is confusing and wide. Some plans "carve out" mental
health benefits to be administered by a different company than the one
that handles medical benefits. The major types of plans include:
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Indemnity Insurance |
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This type of plan
typically does not require pre-authorization and is limited only by a
dollar amount maximum per year (which equates to a specified number of
visits). After paying a deductible, you are able to use as many visits
an necessary up to the annual maximum, paying a co-payment each visit.
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Health Maintenance
Organization (HMO) |
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HMOs have a
contract with providers who form a panel from whom you can select.
In some instances, you need to get a referral from your primary care
doctor before making an appointment. There is usually a maximum
dollar amount / number of sessions, and the managed care company
will evaluate the number of sessions authorized based upon medical necessity.
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Preferred Provider Organization
(PPO) |
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PPO plans allow
more choice of who you can see. You may pay a slightly higher
co-payment or a greater deductible to see someone who is not on the
list of providers contracted with the company.
Point of Service
(POS) plans are similar, as are Exclusive Provider
Organizations (EPO). Pre-authorization of care is often not
required and benefits are frequently not managed.
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Self-Insurance |
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This plan involves
a company setting up their own health insurance in-house to pay
mental health and/or medical costs for their workers.
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