Common use of Medical Necessity Criteria Clause in Contracts

Medical Necessity Criteria. The Contractor shall have a comprehensive UM Program that reviews services for Medical Necessity and clinical appropriateness, and that monitors and evaluates on an ongoing basis the appropriateness of care and services for physical and behavioral health. The Contractor shall comply with federal and state regulations when selecting Medical Necessity criteria. The Contractor shall adopt Interqual or MCG (Milliman) as the primary medical/surgical criteria for Medical Necessity except that the Contractor shall utilize the American Society of Addiction Medicine (ASAM) for substance use. If Interqual or MCG does not cover a Behavioral Health Service, the Contractor shall adopt the following standardized tools for Medical Necessity determinations: