Is your Provider "acceptable" by your insurance?

By Martine G. Brousse (not AI!)

"The Medical Bill Whisperer"™

Patient Advocate, Certified Mediator

AdvimedPro

May 7, 2025

Why would an insurance deny a charge as “provider not licensed for this type of service” or “outside scope of license”? 

What does that mean? What are 3 major causes and solutions? Let’s explore.

A.    Main causes:

1.     Incorrect or Unrelated Diagnosis code

·      Each procedure or service must match with a specific diagnosis. If outside the scope of a medical license, the insurance will deny those charges.

Examples:

·      speech therapy session billed as "autism" for an autistic child would be denied, as speech therapists cannot treat autism. They should use a diagnosis that relates to a 

speech impairment or other speech-related condition.

·      chemotherapy ordered by a PCP: chemotherapy cannot usually be prescribed or 

administered by a PCP. An oncologist must be involved. Chemo by a PCP goes beyond the 

scope of practice or of their license. 

2.     Missing credentials  

Mostly an issue with those out of network invoices that you receive from a provider, and submit to your insurance for reimbursement, rejections for lack of credentials can mean:

·      The provider’s NPI number is missing. This is the National Provider Identifier, which

 individuals providing medical care in the US must obtain and use for administrative and 

financial transactions with a health plan. (Yes, that includes an invoice given to you even if 

you have already paid the bill in full).

·      The name is the provider is not followed by their type of license or degree. Is the provider a MD, a PhD, a LCSW or a PA?    

3.     Services are not considered “medical”  

·    Even if services have been prescribed or recommended by an actual physician, services 

rendered by non-medical professionals (i.e. without a medical license or without proper 

credentials) are not payable.

·    Services considered “alternative or complementary therapy or medicine”, or that are not considered standard of care medical treatments, are usually not covered.

·    Example: A massage given by a DPT or Occupational Therapist is considered “Therapeutic” and therefore covered. However, a massage performed by masseuse is “elective” or “convenience”, and therefore not covered.

·   Therefore, some denials are justified, and even if you appeal, those charges would not 

be reimbursed or payable.   

B.    Solutions  

1.   Correct the coding

·    The billing provider must correct any diagnosis code and resubmit or give you a 

corrected invoice. 

·    Do not send it back to the insurance as a new claim, but as a “corrected claim” to avoid a rejection as a duplicate.   

2.     Add those credentials!

·    The billing provider or biller must add those credentials as well as any NPI 

that may be missing (or Tax ID# or contact info!)

·    Do re-submit as a “correction” to avoid a rejection as a duplicate   

3.     Make sure that your claims are payable

·    Avoid wasting your time sending charges for processing and reimbursements only to get

rejections or denials, then file appeals or make calls for nothing if a provider does not have 

a medical degree, professional license or accreditation. Those services are out of your pocket. 

·    Investigate and look through your Summary of Benefits. Some plans are more generous 

than others, and may cover modalities or services that other plans do not.

·   When in doubt, avoid frustration and a waste of time and efforts by contacting your 

insurance directly to find out whether or not it is worth your while trying to get reimbursed.

Are those services considered “non-medical” or “excluded”. If they are, maybe looking for a alternative In Network option may save you $.

Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.  

www.advimedpro.com - info@advimedpro.com - (424) 999 4705 - F (424) 226 1330 @martine brousse 2025 @ the medical bill whisperer 2025™