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Diagnostic Assessment sessions

mboron 3 years ago in Billing/Electronic Modules updated by Richard Sethre, Psy.D., L.P. 3 years ago 1

Does anyone know if Commercial insurance plans only allow a certain number of Diagnostic Assessments to be billed to them in a year? 

Unfortunately, the answer to that is,  "it depends" - it depends upon the patient's contact and the plan's medical necessity guidelines and utilization review thresholds.  A company with properly transparent policies should provide a clear statement in their provider manual or review threshold guidelines if they have a limit on DAs per year. If the patient has a PMAP policy (Medicaid managed by a commercial plan), the plan's policy should, by contract with DHS, mirror the MA guidelines for DAs. 


You can always call the company's provider relations help line to find out what the staff think the policy is (tip: always take notes, and document the name of the staff, date of discussion and the info you received).  If you are over the company's threshold for DAs in a year, you can make a case for the medical necessity of doing another DA; this usually would require documenting a significant change in the patient's symptoms or circumstances or a lack of response to treatment that would support the need for reassessing their diagnosis and using this info to improve your treatment plan.