Why Was Your Bloodwork Denied? Understanding the ACA’s Coverage for Diagnostic Services

In a recent case, an individual lamented the denial of their bloodwork costs, citing a vague message from their insurer stating that the services were not covered due to the patient’s coverage not providing for diagnostic services for routine conditions or screening services for non-routine conditions. This prompted us to delve deeper into the Affordable Care Act (ACA) and its implications for diagnostic services.

Under the ACA, health insurance plans must cover essential health benefits (EHBs), including diagnostic services such as bloodwork. However, there are certain limitations to this coverage.

Routine vs. Non-Routine Services

The ACA defines routine services as those that are typically provided to healthy individuals to detect or prevent disease and are not related to a specific medical condition. Examples include annual physicals and screenings for common illnesses like the flu.

Non-routine services, on the other hand, are those that are necessary to diagnose or treat a specific medical condition. Bloodwork to assess anemia and gastroesophageal reflux disease (GERD), as in the case, would typically fall under this category.

Coverage for Routine vs. Non-Routine Services

ACA-compliant plans must cover diagnostic services for non-routine conditions without any restrictions. However, coverage for routine services may be limited or subject to certain requirements.

For example, some plans may require pre-authorization for certain types of routine services. Others may have a deductible or coinsurance that applies to these services.

Limitations in Coverage for Diagnostic Services

In some cases, bloodwork may be denied if it is considered unnecessary or not medically indicated. This could happen if the physician does not provide sufficient documentation to justify the need for the test or if there is a more cost-effective alternative.

What to Do if Your Claim Is Denied

If your bloodwork claim is denied, you should first contact your insurance company to inquire about the reason. They may be able to provide a more detailed explanation or help you appeal the decision.

You can also reach out to a licensed insurance agent who can guide you through the process and assist you in understanding your insurance coverage.

Conclusion

Understanding the ACA’s coverage for diagnostic services is crucial to avoid unexpected medical expenses. Remember, bloodwork and other diagnostic services for non-routine conditions are covered by ACA-compliant plans without any restrictions. If you have concerns or questions about your coverage, do not hesitate to contact your insurer or a licensed insurance agent for clarification.