I wonder whether a health insurance in the United States must provide a listing of procedure and diagnosis codes that are covered, if requested by a policyholder?
In my opinion, the listing of procedure codes that are covered should be part of the health insurance contract, and subsequently be made available to the policyholder, but the health insurance I am in discussion with (namely Blue Cross Blue Shield of Massachusetts) seems unwilling to provide such a list (see below for the exact message they sent me).
I am mostly interested in the following locations:
- California, United States
- Massachusetts, United States
Here is the message I received from my health insurance, Blue Cross Blue Shield of Massachusetts, when I asked them "Where can I find the list of all procedure codes, marked as covered or not covered by my insurance plan?":
We do not have a listing of procedure codes that are covered or not covered that we can provide you with. We can check on certain procedure codes when they are provided to us, to see if they are covered based on medical policy guidelines. If you have codes from your provider you can contact us to check on them for you, however, the best way to find out is for the doctor to call provider services to confirm coverage.
More details after further insisting:
The procedure code alone is not what determines if a service will be covered, it is just one piece of the puzzle. Claims are billed with a procedure code and a diagnosis code. The procedure code is what tells us what service is done, and the diagnosis code tells us why. Not only does the procedure code need to be related to a covered service, but the reason for the service (the diagnosis) needs to indicate that the service was medically necessary. We do not have a list of all covered procedures and the related diagnosis codes and we are not clinically trained to determine medical necessity. Typically, it is the doctor’s responsibility to verify if the services are covered and that they are medically necessary. We can research the procedure code that the doctor plans to bill with to see if it is a service that we would potentially cover, but we cannot advise you if it is medically necessary.