Medical necessity review definition

Medical necessity review means an assessment of current and recent behaviors and symptoms to determine whether an admission for inpatient mental illness or drug or alcohol dependence treatment or evaluation constitutes the least restrictive level of care necessary. The review shall be performed by a licensed mental health professional;
Sample 1Sample 2Sample 3
Medical necessity review means a review of the social and medical needs of a resident, whose stay is being paid by
Sample 1Sample 2
Medical necessity review means a review of the social and medical needs of aresident, whose stay is being paid by Medicaid or Medicare or other third party payor, to determine the appropriate level of care of such resident;
Sample 1

Examples of Medical necessity review in a sentence

  • Medical necessity review may take place prospectively, as part of the inpatient admission notification/concurrent review, or retrospectively.

  • Medical necessity review shall utilize an evidence-based and peer reviewed clinical review tool to be designated through rulemaking by the Commissioner of Human Services in consultation with the Department of Health.

  • Medical necessity review is required to determine if a specific organ or tissue transplant service will be covered.

  • Medical necessity review is required to determine if a specific organ or tissue transplant service will be covered.When a human organ or tissue transplant is provided from a living donor to a covered person, both the recipient and the donor may receive the benefits of the health Plan.

  • Medical necessity review required after 80 units per State fiscal year (July 1 – June 30).Clinical GuidelinesSelect Health of South Carolina and the AmeriHealth Caritas Family of Companies (ACFC) have established a Clinical Policy Committee (CPC) to develop local and corporate medical guidelines.

  • The guidelines used include: • Health Plan Medical Policies• Medicare coverage guidelines• Medicaid coverage guidelines• MCG Guidelineso Inpatient and Surgical Careo General Recovery Careo Ambulatory Careo Recovery Facility Careo Home Careo Behavioral Health Care Medical necessity review takes into consideration the needs of the individual patients and characteristics of the local delivery system, and with the advice of practicing physicians who are members of the IPA or with external peer reviewers.

  • See page 106.• Medical necessity review guidance has been added to specific procedures in Blood or Marrow Stem Cell Transplants under clinical trials.• Chronic lymphocytic lymphoma/small lymphoma (CLL/SLL) and Myeloproliferative/Myelodysplastic Syndromes.

  • Medical necessity review by all of CMS’s contractors has produced thousands of IRF appeals in the past decade, a high percentage of which were settled in favor of IRF providers (between 69% and 100% depending on the type of denial) in 2018.

  • Medical necessity review required after 80 units per state fiscal year (July 1 – June 30).Clinical guidelinesSelect Health of South Carolina and the AmeriHealth Caritas Family of Companies have established a Clinical Policy Committee (CPC) to develop local and corporate medical guidelines.

  • Medical necessity review guidelines.‌ Service Initiation: (1) Adult Peer Support Services.


More Definitions of Medical necessity review

Medical necessity review means an assessment of current and recent behaviors and symptoms to determine whether an admission for inpatient mental illness or drug or alcohol dependence treatment or evaluation constitutes the least restrictive
Sample 1
Medical necessity review means an assessment of current
Sample 1

Related to Medical necessity review

  • Medical necessity means that the service or supply is provided by a physician or other health care provider exercising prudent clinical judgment for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that provision of the service or supply is:

  • Utilization review plan or "plan" means a written procedure for performing review.

  • Clinical nurse specialist means a registered nurse with relevant post-basic qualifications and 12 months’ experience working in the clinical area of his/her specified post-basic qualification, or a minimum of four years’ post-basic registration experience, including three years’ experience in the relevant specialist field and who satisfies the local criteria.

  • Medical examination means the preliminary assessment of a person by an authorized health worker or by a person under the direct supervision of the competent authority, to determine the person’s health status and potential public health risk to others, and may include the scrutiny of health documents, and a physical examination when justified by the circumstances of the individual case;

  • Supervising physician means any physician licensed under Iowa Code chapter 148, 150, or 150A. The supervising physician is responsible for medical direction of emergency medical care personnel when such personnel are providing emergency medical care.

  • Medical Review Officer (MRO means a licensed physician, employed with or contracted with the City, responsible for receiving laboratory results generated by the City's drug testing program who has knowledge of substance abuse disorders, laboratory testing procedures, and chain of custody collection procedures; who verifies positive, confirmed test results, and who has the necessary and appropriate medical training to interpret and evaluate an individual's confirmed positive test result together with his or her medical history and any other relevant biomedical information.

  • psychiatric emergency medical condition means a Mental Disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either of the following:

  • Objective medical evidence means reports of examinations or treatments; medical signs which are anatomical, physiological, or psychological abnormalities that can be observed; psychiatric signs which are medically demonstrable phenomena indicating specific abnormalities of behavior, affect, thought, memory, orientation, or contact with reality; or laboratory findings which are anatomical, physiological, or psychological phenomena that can be shown by medically acceptable laboratory diagnostic techniques, including but not limited to chemical tests, electrocardiograms, electroencephalograms, X-rays, and psychological tests;

  • Primary care physician means a physician qualified to be an attending physician according to ORS 656.005(12)(b)(A) and who is a general practitioner, family practitioner, or internal medicine practitioner.

  • Medical Review Officer (MRO) means a licensed physician responsible for receiving and reviewing laboratory results generated by the school district’s drug testing program and for evaluating medical explanations for certain drug tests.

  • Stewardship means the continuing obligation to provide the necessary maintenance, management, protection, husbandry and support for a natural area and natural values associated with that area.

  • Clinical review criteria means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a health carrier to determine the necessity and appropriateness of health care services.

  • Independent testing laboratory means an independent organization, accepted by the Contracting Officer, engaged to perform specific inspections or tests of the work, either at the site or elsewhere, and report the results of these inspections or tests.

  • Medical cannabis pharmacy means the same as that term is defined in Section 26-61a-102.

  • Medical Specialist means any medical practitioner who is vocationally registered by the Medical Council under the Health Practitioners Competence Assurance Act 2003 in one of the approved branches of medicine and who is employed in either that branch of medicine or in a similar capacity with minimal oversight.

  • Medical Reimbursement Programs means a collective reference to the Medicare, Medicaid and TRICARE programs and any other health care program operated by or financed in whole or in part by any foreign or domestic federal, state or local government and any other non-government funded third party payor programs.

  • Licensed mental health professional or "LMHP" means a physician, licensed clinical psychologist, licensed professional counselor, licensed clinical social worker, licensed substance abuse treatment practitioner, licensed marriage and family therapist, certified psychiatric clinical nurse specialist, licensed behavior analyst, or licensed psychiatric/mental health nurse practitioner.

  • Medical cannabis means the same as that term is defined in Section 26-61a-102.

  • Designated mental health professional means a mental health

  • Medical history means information regarding any:

  • Qualified mental health professional means a licensed medical practitioner or any other person meeting the qualifications specified in OAR 309-019-0125.

  • Medical physicist means a person trained in evaluating the performance of mammography equipment and facility quality assurance programs and who meets the qualifications for a medical physicist set forth in 41.6(3)“c.”

  • Mental health professional means a psychiatrist,

  • Quality Assurance Program means the overall quality program and associated activities including the Department’s Quality Assurance, Design-Builder Quality Control, the Contract’s quality requirements for design and construction to assure compliance with Department Specifications and procedures.

  • Utilization review means the prospective (prior to), concurrent (during) or retrospective (after) review of any service to determine whether such service was properly authorized, constitutes a medically necessary service for purposes of benefit payment, and is a covered healthcare service under this plan. WE, US, and OUR means Blue Cross & Blue Shield of Rhode Island. WE, US, or OUR will have the same meaning whether italicized or not. YOU and YOUR means the subscriber or member enrolled for coverage under this agreement. YOU and YOUR will have the same meaning whether italicized or not.

  • Participating Certified Clinical Nurse Specialist means a Certified Clinical Nurse Specialist who has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.