Common use of Medical Case Management Clause in Contracts

Medical Case Management. A program that allows a consultant to review the medical treatment for an individual to determine whether the covered person does or does not qualify for alternate medical treatment benefits. The determination for a patient's medical case management eligibility will be primarily based upon medical necessity and appropriate medical care. The Plan Administrator will recommend alternate medical treatment on a case-by-case basis. Alternate medical treatment benefits refer to expenses that are approved before they are incurred, which may not otherwise be payable as covered expenses under the medical plan.