Covered Services

Healthcare services and procedures that are included in an insurance plan's benefits, meaning the payer will reimburse all or part of the cost when rendered by an eligible provider to an eligible member.

Covered services are the specific healthcare services, treatments, and procedures that a health insurance plan will pay for. If a service is not covered, the payer will deny the claim regardless of medical necessity. Each plan defines its covered services in the member's Summary of Benefits and Coverage document and in the full plan document. The Affordable Care Act requires all marketplace plans to cover 10 essential health benefit categories, but the specific services within each category can vary. Employer-sponsored plans and Medicaid plans have their own benefit structures. As a provider, you need to understand the covered services for the major plans you participate in because it directly affects what you can bill for. If you perform a service that is not covered by the patient's plan, you are responsible for informing the patient before the service that they will be paying out of pocket. An Advance Beneficiary Notice (ABN) is required for Medicare patients when you believe a service might not be covered. Covered services are not the same as authorized services. A service might be covered by the plan in general, but still require prior authorization for a specific patient in specific circumstances. The claim can still be denied even for a covered service if the payer determines it was not medically necessary. When you are evaluating whether to participate with a payer, look at what services they cover in your specialty. Some payers have narrow coverage for certain specialties or exclude services that are central to your practice. Signing a contract with a payer that does not cover most of what you do is not worth the administrative effort.