Overview
Claims may be denied when a service is considered medically unnecessary, experimental, or investigational under the plan's coverage rules. These determinations are generally based on clinical criteria and the plan's Summary Plan Description (SPD), rather than the standard claim pricing or benefit calculations.
Who makes the determination
There are two common reasons for these denials:
Utilization Management (UM) vendor: For services requiring prior authorization, the UM vendor reviews medical necessity and determines whether the requested service meets the applicable clinical criteria. Yuzu receives these decisions through the vendor's authorization files and applies them during claims adjudication.
Plan exclusions: Some services are excluded under the plan's SPD, including treatments classified as experimental or investigational. These exclusions are configured in Yuzu and may result in a denial even if the claim otherwise matches a covered benefit.
Yuzu does not independently make clinical determinations. To investigate a denial, check whether it originated from a denied prior authorization or a plan exclusion applied during adjudication.
How the SPD applies
The SPD defines the plan's medical necessity requirements and exclusions for experimental or investigational services.
The UM vendor uses the applicable plan criteria when reviewing prior authorizations, while Yuzu applies configured benefit exclusions during adjudication.
If a service appears to have been incorrectly excluded, the plan configuration should be reviewed against the SPD.
Appealing a denial
The appropriate next step depends on the reason for the denial:
UM vendor denial: The member or provider should follow the applicable appeal process with the UM vendor or plan, including submitting supporting clinical documentation.
Plan exclusion: Review the SPD and applicable appeal procedures to determine whether the exclusion was correctly applied. If the issue is an incorrect benefit configuration, escalate it for review.
If an appeal overturns the denial or the plan configuration is corrected, the claim may be eligible for reprocessing.