Review of Medical Necessity. It is important to remember that any review of Medical Necessity by us is solely for the purposes of determining coverage, benefits, or payment under the terms of this Contract and not for the purpose of recommending or providing medical care. In this respect, we may review specific medical facts or information pertaining to you. Any such review, however, is strictly for the purpose of determining whether a Health Care Service provided or proposed meets the definition of Medical Necessity in this Contract, as determined by us. In applying the definition of Medical Necessity in this Contract to a specific Health Care Service, we will apply our coverage and payment guidelines then in effect. You are free to obtain a service even if we deny coverage because the service is not Medically Necessary; however, you will be solely responsible for paying for the service.
Review of Medical Necessity. Caremark has contracted with an independent vendor or vendors for the processing of appeals resulting from a denial of authorization of prescription benefits where the Plan beneficiary is entitled to obtain a review of the denial by an independent physician specialist. Caremark has entered or will enter into an agreement with the independent vendor(s), which provides for an appeals process consistent with the Appeals Program. With respect to such reviews, the independent vendor shall act as a fiduciary and shall have the sole and absolute discretion to interpret the Plan Document and to make factual findings. The decision of the independent vendor shall be final, subject to External Review under Section 4 of this Attachment 1 to this Exhibit or available judicial review only for abuse of discretion.
Review of Medical Necessity. APS shall develop and apply standards of Medical Necessity, appropriateness and efficiency which reflect patterns of care found in established managed behavioral health care environments and that are consistent with the applicable Benefit Contract. APS shall involve an appropriately licensed behavioral health care professional whenever rendering a recommendation that mental health and/or substance abuse services that have been requested or for which payment has been requested are not Medically Necessary consistent with the applicable Benefit Contract. In the event of a dispute regarding whether requested services are Medically Necessary, such dispute shall be resolved pursuant to SECTION 6.4. OR 6.5, as applicable.
