Insurer's must pay "in-network" benefits to "out-of-network" providers when an "in-network" provider is not available or qualified as per the guidelines outlined herein, to provide treatment as ordered by the treating physician. Insurer's must provide coverage according to the policy even after the policy is no longer in force or effective when a claim or prior authorization request was submitted prior to the termination date, but inappropriately denied, which may be determined by a state's insurance commissioner or by a state medical examiner's board, if the decision to deny is made by a medical director who is a licensed physician. Insurer's may not contact the patient or ordering physician for any reason other than to confirm basic information, such as mailing addresses, phone number, or date of birth. Insurer's may not contact the patient or ordering physician to discuss treatment options or to suggest or request any revisions of the physician's order. Insurer's may not request or require providers to submit confidential or proprietary information including invoices, except in the case when reimbursement is cost times two, any financial records, or confidential patient records in order to approve coverage or reimburse for medical services, physical therapy, or durable medical equipment as outlined herein.
Insurer's may not discriminate, prohibit, obstruct, mislead, defraud or prevent in any way for any reason, qualified and certified providers from providing, contracting, or obtaining reimbursement for services, supplies or treatment as ordered by the treating physician for their beneficiaries. Any person(s) or company or insurer which engages in this activity will be subject to Titles 14 and 18 of the US code. Physical Therapy with application of Manual Lymph
Drainage
a. shall be provided and applied by a licensed physical therapist, occupational therapist, licensed practical nurse, licensed message therapist, or registered nurse, LANA certified, with an additional 135 hours of certified training for manual lymph drainage and/or combined decongestive physiotherapy.
b. Physical therapy shall require the application of a reasonable amount of time for treatment, and not less than one hour of application of MLD/CDP, one hour for application of external compression, and one half hour for patient education on disease self-care, and home management. Insurers must allow for coverage on extended treatment time, application of external compression, and patient education on disease self-care when the condition is severe and/or more than one extremity or area of the body is affected, or when there are other circumstances requiring additional time, as determined, documented in a letter of medical necessity, and ordered by the treating physician.
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