Medical Necessity. As defined in Hawaii Revised Statutes (“HRS”) 432E-1.4, for health interventions that the health plans are required to cover within the specified categories, a health intervention is medically necessary if it is recommended by the treating physician or treating licensed health care provider, is approved by health plan’s medical director or physician designee, and is: (i) For the purpose of treating a medical condition; (ii) The most appropriate delivery or level of service, considering potential benefits and xxxxx to the patient; (iii) Known to be effective in improving health outcomes; provided that: a. Effectiveness is determined first by scientific evidence; b. If no scientific evidence exists, then by professional standards of care; and c. If no professional standards of care exist or if they exist but are outdated or contradictory, then by expert opinion; and (iv) Cost-effective for the medical condition being treated compared to alternative health interventions, including no intervention. For purposes of this paragraph, cost-effective shall not necessarily mean the lowest price. For purposes of this Section:
Appears in 5 contracts
Samples: Provider Agreement, Hawaii State Programs Regulatory Requirements Appendix, Hawaii State Programs Regulatory Requirements Appendix
