Medical Necessity Determination. The Contractor shall determine which services are medically necessary, according to utilization management requirements and the definition of Medically Necessary Services in this Contract. The Contractor’s determination of medical necessity in specific instances shall be final except as specifically provided in this Contract regarding appeals, hearings and independent review.
Medical Necessity Determination. 2.6.3.1 The CONTRACTOR may establish procedures for the determination of medical necessity. The determination of medical necessity shall be made on a case by case basis and in accordance with the definition of medical necessity defined in TCA 71- 5-144 and TennCare rules and regulations. However, this requirement shall not limit the CONTRACTOR’s ability to use medically appropriate cost effective alternative services in accordance with Section 2.6.5.
2.6.3.2 The CONTRACTOR shall not employ, and shall not permit others acting on their behalf to employ, utilization control guidelines or other quantitative coverage limits, whether explicit or de facto, unless supported by an individualized determination of medical necessity based upon the needs of each TennCare enrollee and his/her medical history. The CONTRACTOR shall have the ability to place tentative limits on a service; however, such tentative limits placed by the CONTRACTOR shall be exceeded (up to the applicable benefit limits on behavioral health and long-term care services provided in Section 2.6.1.4 and 2.6.1.5 above) when medically necessary based on a member’s individual characteristics.
2.6.3.3 The CONTRACTOR shall not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of the diagnosis, type of illness, or condition.
2.6.3.4 The CONTRACTOR may deny services that are non-covered except as otherwise required by TENNderCare or unless otherwise directed to provide by TENNCARE and/or an administrative law judge.
2.6.3.5 All medically necessary services shall be covered for enrollees under twenty-one (21) years of age in accordance with TENNderCare requirements (see Section 2.7.6).
Medical Necessity Determination. Health Plan’s determination with regard to Medically Necessary services and scope of Covered Services, including determinations of level of care and length of stay benefits available under the Member’s health program shall govern. The primary concern with respect to all medical determination shall be in the interest of the Member.
Medical Necessity Determination. 3.4.5.1 The Contractor shall provide Covered Services consistent with the State’s definition of Medical Necessity, as provided below.
3.4.5.1.1 Medical Necessity is defined as the essential need for health care or services which, when delivered by or through authorized and qualified providers, will:
3.4.5.1.1.1 Be directly related to the prevention, diagnosis and treatment of a member’s disease, condition, and/or disorder that results in health impairments and/or disability (the physical or mental functional deficits that characterize the member’s condition), and be provided to the member only;
3.4.5.1.1.2 Be appropriate and effective to the comprehensive profile (e.g., needs, aptitudes, abilities, and environment) of the member and the member’s family;
3.4.5.1.1.3 Be primarily directed to the diagnosed medical condition or the effects of the condition of the member, in all settings for normal activities of daily living (ADLs), but will not be solely for the convenience of the member, the member’s family, or the member’s provider;
3.4.5.1.1.4 Be timely, considering the nature and current state of the member’s diagnosed condition and its effects, and will be expected to achieve the intended outcomes in a reasonable time;
3.4.5.1.1.5 Be the least costly, appropriate, available health service alternative, and will represent an effective and appropriate use of funds;
3.4.5.1.1.6 Be the most appropriate care or service that can be safely and effectively provided to the member, and will not duplicate other services provided to the member;
3.4.5.1.1.7 Be sufficient in amount, scope and duration to reasonably achieve its purpose;
3.4.5.1.1.8 Be recognized as either the treatment of choice (i.e., prevailing community or Statewide standard) or common medical practice by the practitioner’s peer group, or the functional equivalent of other care and services that are commonly provided; and
3.4.5.1.1.9 Be rendered in response to a life threatening condition or pain, or to treat an injury, illness, or other diagnosed condition, or to treat the effects of a diagnosed condition that has resulted in or could result in a physical or mental limitation, including loss of physical or mental functionality or developmental delay.
3.4.5.1.1. 10For members enrolled in DSHP Plus LTSS, provide the opportunity for members to have access to the benefits of community living, to achieve person-centered goals, and live and work in the setting of their choice.
3.4.5.1.2 In order that the m...
Medical Necessity Determination. 2.6.3.1 The CONTRACTOR may establish procedures for the determination of medical necessity. The determination of medical necessity shall be made on a case by case basis and in accordance with the definition of medical necessity defined in TCA 71- 5-144 and TennCare rules and regulations. However, this requirement shall not limit the CONTRACTOR’s ability to use medically appropriate cost effective alternative services in accordance with Section A.2.6.5.
2.6.3.2 The CONTRACTOR shall not employ, and shall not permit others acting on their behalf to employ, utilization control guidelines or other quantitative coverage limits, whether explicit or de facto, unless supported by an individualized determination of medical necessity based upon the needs of each TennCare enrollee and his/her medical history. The CONTRACTOR shall have the ability to place tentative limits on a service; however, such tentative limits placed by the CONTRACTOR shall be exceeded (up to the applicable benefit limits on behavioral health and long-term care services provided in Section A.2.6.1.4
Medical Necessity Determination. 2.6.3.1 The CONTRACTOR may place appropriate limits on a covered benefit. In accordance with the TennCare medical necessity rules, the CONTRACTOR may establish procedures for the determination of medical necessity and for the use of medically appropriate cost effective alternative benefits. The CONTRACTOR may also limit benefits for the purpose of utilization control in accordance with NCQA standards, as long as (1) the furnished benefits can reasonably achieve the purpose for which they are furnished, and as long as (2) the benefits furnished for enrollees with chronic conditions (or who require LTSS) are authorized in a manner that reflects the enrollee’s ongoing need for such benefits. See 42 C.F.R. §438.3(e)(2) and 42 C.F.R. §438.210(a)(4). Additionally, the CONTRACTOR shall include in its review of medical necessity for CHOICES, ECF CHOICES, and 1915(c) waiver HCBS and HCBS-related services, including Durable Medical Equipment, for individuals receiving HCBS in CHOICES, ECF CHOICES, or a Section 1915(c) HCBS Waiver, whether the HCBS or related service provide an opportunity for the member receiving long-term services and supports to have access to the benefits of community living, achieve person-centered goals, be free of undue restraint, and live and work in the setting of their choice as prescribed in TennCare policy.
2.6.3.2 The CONTRACTOR shall use written criteria based on sound clinical evidence to make utilization decisions. The written criteria shall specify procedures for appropriately applying the criteria. The criteria must satisfy NCQA standards. The CONTRACTOR shall apply objective and evidence-based criteria and take individual circumstances and the local delivery into account when determining the medical appropriateness of health care services.
2.6.3.3 The CONTRACTOR shall ensure that the services are sufficient in amount, duration, or scope to reasonably achieve the purpose for which the services are furnished. The CONTRACTOR shall not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of the diagnosis, type of illness, or condition.
2.6.3.4 The CONTRACTOR may deny benefits which are excluded under TennCare rule and may premise such denial on the applicable exclusion rule.
2.6.3.5 Prior to any reduction of home health or private duty nursing services prescribed by a treating physician for a chronic condition, the CONTRACTOR shall review nursing and aide care notes and the results of face-to-f...
Medical Necessity Determination. 2.6.3.1 The CONTRACTOR may establish procedures for the determination of medical necessity. The determination of medical necessity shall be made on a case by case basis and in accordance with the definition of medical necessity defined in TCA 71-5-144 and TennCare rules and regulations. However, this requirement shall not limit the CONTRACTOR’s ability to use medically appropriate cost effective alternatives in accordance with Section 2.6.5.
2.6.3.2 The CONTRACTOR shall not employ, and shall not permit others acting on their behalf to employ, utilization control guidelines or other quantitative coverage limits, whether explicit or de facto, unless supported by an individualized determination of medical necessity based upon the needs of each TennCare enrollee and his/her medical history. The CONTRACTOR shall have the ability to place tentative limits on a service; however, such tentative limits placed by the CONTRACTOR shall be exceeded (up to the applicable hard limit on detoxification provided in Section 2.6.1.4 above) when medically necessary based on a member’s individual characteristics.
2.6.3.3 The CONTRACTOR shall not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of the diagnosis, type of illness, or condition.
2.6.3.4 The CONTRACTOR may deny services that are non-covered except as otherwise required by TENNderCare or unless otherwise directed to provide by TENNCARE and/or an administrative law judge.
2.6.3.5 All medically necessary services shall be covered for enrollees under twenty-one (21) years of age in accordance with TENNderCare requirements (see Section 2.7.5).
Medical Necessity Determination. Standard Review: In the event that an Appeal of an Adverse Benefit Determination is based in whole or in part on Medical Necessity, and the Insured is not satisfied with the outcome of the Appeal review process as explained in this section of the Certificate, the Insured has the right, but not the obligation, to submit the Appeal to external review. External review Appeals are conducted by independent review organizations (IROs), selected by the Nevada Office for Consumer Health Assistance (OCHA). Except when agreed upon by both parties, or when we fail to follow the established appeals procedure as described above, the internal review process must be exhausted before an Appeal can be submitted for external review. The Health Plan will pay for the costs of the external review, including filing, administrative, and reviewer fees. Any statute of limitations or other defense based on timeliness will not be counted during the time that an external review is pending.
Medical Necessity Determination. Contractor shall provide NTP/OTP services to clients if determined medically necessary in accordance with the Intergovernmental Agreement and Title 22 California Code of Regulations (C.C.R.) Sections 51303 and Welfare and Institutions Code sections 14184.402, subd. (a) and 14059.5 and BHINs 21-071 and 23-001. Services shall be prescribed by a physician, and are subject to utilization controls, as specified in Title 22 C.C.R. Section 51159. The OTP services shall be directed at stabilization, rehabilitation, and detoxification of persons who are opiate addicted and have substance abuse diagnoses.
Medical Necessity Determination. Health Plan’s determination regarding Medical Necessity, including, but not limited to, determinations of level of care and length of stay, will govern.
