Insured Services Guidelines

Welcome to the Equity Afya Insured Services Guidelines training. This comprehensive guide will help you understand what's covered, what's not, and the key considerations when serving insured clients.

At Equity Afya, duty of care is paramount. When a qualified healthcare professional deems treatment medically necessary, it must be offered regardless of insurance coverage. Patients have the right to know their diagnosis, treatment options, and costs. If insurance doesn't cover a necessary service, clearly communicate the out-of-pocket payment option.

Key emerging exclusions require prior authorization and must match the diagnosis. These include dewormers like Albendazole and Mebendazole, probiotics such as Floranorm and Enterogermina, supplements like Pregnacare and Osteocare, moisturizers and sunscreens, mouthwashes, cold medications, and herbal products. Always verify coverage before prescribing.

Standard exclusions include non-essential services, cosmetic procedures, and alternative therapies. Be aware of nonspecific diagnoses that insurers may reject. Always use specific ICD-10 codes and avoid vague terms in documentation to prevent claim denials.

Thorough diagnosis and documentation using ICD-10 codes is crucial. Insurance reports must be submitted within 48 hours. Ensure all diagnoses are specific and properly coded to avoid claim rejections. Documentation should clearly justify all prescribed treatments and procedures.

Prescription practices should prioritize definitive treatments and generic brands whenever possible. Every prescription must align with the documented diagnosis. Choose cost-effective options that maintain quality care while respecting insurance guidelines.

All laboratory and imaging tests must be clinically justified and properly documented. Avoid unnecessary tests that increase costs without improving patient outcomes. Each test ordered should have a clear clinical indication linked to the patient's presenting symptoms and diagnosis.

Always prioritize patient care while following insurance guidelines. Keep this training fresh in your mind: offer necessary care regardless of coverage, inform patients of their options, use proper ICD-10 codes, submit reports within 48 hours, and justify all treatments. For questions, consult the full guidelines document or your supervisor. Together, we deliver excellent care at Equity Afya.