Common use of Medically Necessary Services Clause in Contracts

Medically Necessary Services. Medicaid services (as defined under s. 49.46, Wis. Stats., and ch. 107 Wis. Admin. Code) that are required to prevent, identify or treat a member’s illness, injury or disability; and that meet the following standards: a) Are consistent with the member’s symptoms or with prevention, diagnoses or treatment of the member’s illness, injury or disability; b) Are provided consistent with standards of acceptable quality of care applicable to the type of service, the type of provider and the setting in which the service is provided; c) Are appropriate with regard to generally accepted standards of medical practice; d) Are not medically contraindicated with regard to the member’s diagnoses, symptoms, or other medically necessary services being provided to the member; e) Are of proven medical value or usefulness and, consistent with ch. DHS 107.035 Wis. Admin. Code, are not experimental in nature; f) Are not duplicative with respect to other services being provided to the member; g) Are not solely for the convenience of the member, the member’s family or a provider; h) With respect to prior authorization of a service and other prospective coverage determinations made by DHS, are cost-effective compared to an alternative medically necessary service which is reasonably accessible to the member; and, i) Are the most appropriate supply or level of service that can safely and effectively be provided to the member.

Medically Necessary Services. Medicaid services (as defined under s. 49.46, Wis. Stats., Stat. § 49.46 and ch. 107 Wis. Admin. Code) Code § DHS 107 that are required to prevent, identify or treat a member’s illness, injury or disability; and that meet the following standards: a) Are consistent with the member’s symptoms or with prevention, diagnoses or treatment of the member’s illness, injury or disability; b) Are provided consistent with standards of acceptable quality of care applicable to the type of service, the type of provider and the setting in which the service is provided; c) Are appropriate with regard to generally accepted standards of medical practice; d) Are not medically contraindicated with regard to the member’s diagnoses, symptoms, or other medically necessary services being provided to the member; e) Are of proven medical value or usefulness and, consistent with ch. DHS 107.035 Wis. Admin. Code, Code § DHS 107.035 are not experimental in nature; f) Are not duplicative with respect to other services being provided to the member; g) Are not solely for the convenience of the member, the member’s family or a provider; h) With respect to prior authorization of a service and other prospective coverage determinations made by DHS, are cost-effective compared to an alternative medically necessary service which is reasonably accessible to the member; and, i) Are Is the most appropriate supply or level of service that can safely and effectively be provided to the member.