Medical Specials
Medical Specials NCS Zaps
Assertions and NCS Zap Responses
Assertion: Reduction Based on Collateral Source Payments
Adjuster Assertion: Reduction to Medical Specials based on collateral source payments (e.g., health insurance reimbursements).
NCS Zap Response:
"The reduction of Medical Specials due to collateral source payments violates [state-specific rule/statute], which prohibits such offsets. Under [state law], the full billed amount is recoverable, regardless of third-party payments or adjustments. Please revise your evaluation to reflect the original billed amount of $[Medical Specials Total]."
Assertion: Reduction Based on Usual and Customary (U&C) Rates
Adjuster Assertion: Reduction applied because billed amounts exceed U&C rates.
NCS Zap Response:
"The reduction to Medical Specials based on Usual and Customary (U&C) rates must be supported by jurisdictional fee schedules or industry-standard benchmarks. If the rates provided are inconsistent with [state-specific database/Medicare guidelines], the reduction lacks validity. Please provide documentation supporting the U&C rates applied or revise the total to $[Medical Specials Total]."
Assertion: Lack of Medical Necessity
Adjuster Assertion: Reduction applied due to unnecessary or unrelated treatments.
NCS Zap Response:
"Medical necessity is determined by treating physicians, and any dispute must be supported by independent medical authority, such as an IME or peer review. Reductions to Medical Specials without such documentation are unsupported. Please provide an IME report or similar evidence validating your assertion, or restore the original amount of $[Medical Specials Total]."
Assertion: Pre-Negotiated Rates (Insurance Adjustments)
Adjuster Assertion: Reduction applied due to pre-negotiated insurance rates.
NCS Zap Response:
"Pre-negotiated insurance rates are not admissible as a basis for reducing Medical Specials under [state-specific law/statute]. Damages are calculated based on the amounts billed to the claimant, not discounted rates negotiated by insurers. Please revise the Medical Specials to reflect the original billed amount of $[Medical Specials Total]."
Assertion: Duplicate or Unrelated Services
Adjuster Assertion: Reduction applied for services unrelated to the incident.
NCS Zap Response:
"The reduction of Medical Specials due to unrelated services must be supported by a detailed explanation and reference to specific ICD-10 codes or treatment notes. GENESIS has cross-referenced all records and found no evidence of unrelated treatments. Please provide supporting documentation for this assertion or restore the full amount of $[Medical Specials Total]."