Encountering Medical Insurance Plan Exclusions When Cross Coding

What are plan exclusions?

A health insurance plan exclusion refers to anything the insurance company will not cover, ranging from a type of drug, surgery, or dental procedure. There are a few exceptions to plan exclusions. Depending on the insurance plan they might cover the procedure in the case of accident, injury, tumor, or cancer. Exclusions can vary from plan to plan, and it is essential that you get to know the plan’s exclusions by doing a detailed verification of benefit. How do you do a detailed verification of benefit?

In the Imagn Billing software, you have the ability to add up to 12 diagnosis codes to your verification of benefit. To give our team the ability to ask the insurance more specific questions giving you even more detail about the patient’s plan.

For example, when our team calls they will ask the agent “Are implants covered due to Sjogren’s syndrome?” Sjogrens’s is the diagnosis code that you would add to your verification of benefit. Giving you specific information about the patient plan benefits.

A verification of benefit provides you general plan exclusions however in some cases you will receive the code-specific plan exclusion(s) during pre-authorization. During a pre-authorization, they take a deep look at the plan exclusion for that specific patient and group number. 

Ultimately the insurance company determines the covered benefits and at times you will receive a verification of benefit that says the procedure is covered. Then be told during pre-authorization that the procedure is not covered. The Imagn billing service team will advocate for you every step of the way. However, it is the insurance agent’s interpretation of the plan benefits that make the final call. 

Types of Exclusions 


Code Specific 

Code Specific plan execution(s) let you know if the specific code(s) in question are excluded from the patient’s insurance benefits. 

Overall Plan exclusions  

Overall plan exclusions are when the insurance plan has requirements or conditions that must be met for any of the patient’s benefits to apply. For example, a few common overall plan exclusions include:

  • CPAP Requirement
  • They only pay for trauma cases
  • An appliance or medical device will only be covered once every 3-5 years
  • Implants are only paid due to cancer

What to do if there is a plan exclusion?

If you get notified of a plan exclusion(s) for the recommended procedure in most cases you will stop billing medical and utilize other forms of payment for the treatment plan. However, we advise that you educate your patient on the plan exclusion so that during the next open enrollment period the patient can sign up for a plan that better fits, their needs. 

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