Medically Necessary Covered Services definition

Medically Necessary Covered Services means those covered services provided by qualified service providers within the scope of their practice to prevent disease, disability and other adverse health conditions or their progression or to prolong life. Medically necessary services are aimed at achieving the following: The prevention, diagnosis, and treatment of behavioral health impairments; the ability to achieve age-appropriate growth and development; and the ability to attain, maintain, or regain functional capacity.
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Medically Necessary Covered Services means those covered services provided by qualified service providers within the scope of their practice to prevent disease, disability and other adverse health conditions or their progression or to prolong life.
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Examples of Medically Necessary Covered Services in a sentence

  • When a Plan Participant uses a Participating Provider, this Allowable Charge is used to determine the amount the Plan pays for Medically Necessary Covered Services and the amount the Plan Participant pays.

  • If the Plan Participant uses a Preferred Provider, this Allowable Charge is used to determine the Plan’s payment for the Plan Participant’s Medically Necessary Covered Services and the amount that the Plan Participant must pay for his Covered Services.

  • Benefits for convalescent care provided during the period of recovery from illness or the effects of injury and Surgery are limited to those Medically Necessary Covered Services normally received for a specific Condition.

  • All Medically Necessary Covered Services received in Urgent Care Centers, Retail Clinics or your Primary Care Physician’s office after-hours to treat an Urgent Medical Condition will be covered by AvMed.

  • AvMed will cover office visits to a dermatologist for Medically Necessary Covered Services, subject to the Limitations described in Part X.

  • All Medically Necessary Covered Services of Other Health Care Facilities including Skilled Nursing Facilities, such as Physician visits, physiotherapy, diagnostic imaging and laboratory work, are covered for Conditions that cannot be adequately treated with Home Health Care Services, or on an ambulatory basis, when a Member is admitted to such a facility following discharge from a Hospital.

  • CareFirst will provide the benefits described in the Schedule of Benefits for Medically Necessary Covered Services Incurred by a Member, including any extension of benefits for which the Member is eligible.

  • Services of Participating Physicians for diagnosis, treatment and consultation are provided while You are an inpatient or outpatient in a facility for authorized Medically Necessary Covered Services or Emergency Care as defined herein.

  • The HMO must pay for or reimburse Providers for all Medically Necessary Covered Services provided to all Members.

  • The HMO must provide Medically Necessary Covered Services to all Members beginning on the Member’s date of enrollment regardless of pre-existing conditions, prior diagnosis and/or receipt of any prior health care services.

Related to Medically Necessary Covered Services

  • Medically Necessary Services means those covered services that are, under the terms and conditions of the contract, determined through contractor utilization management to be:

  • Medically Necessary means a service which is appropriate and consistent with the treatment of the condition in accordance with accepted standards of community practice.

  • Medically necessary care means care that is (1) appropriate and consistent with and essential for the prevention, diagnosis, or treatment of a Patient’s condition; (2) the most appropriate supply or level of service for the Patient’s condition that can be provided safely; (3) not provided primarily

  • Medically Necessary Leave of Absence means any change in enrollment at the post-secondary school that begins while the child is suffering from a serious illness or injury, is medically necessary, and causes the child to lose student status for purposes of coverage under the Plan.

  • Covered Services means all or a part of those medical and health services set forth in rule 441—86.14(514I).

  • Dependent care assistance program or "DCAP" means a benefit plan whereby school employees may pay for certain employment related dependent care with pretax dollars as provided in the salary reduction plan under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 129 or other sections of the Internal Revenue Code.

  • 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 personnel means those persons assigned, by a Party to the conflict, exclusively to the medical purposes enumerated under sub-paragraph (e) or to the administration of medical units or to the operation or administration of medical transports. Such assignments may be either permanent or temporary. The term includes:

  • 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.

  • Primary caregiver or "caregiver" means a resident of the State

  • 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.”

  • Urgently Needed Services means Covered Services needed to prevent a serious deterioration in a Member’s health. While not as immediate as Emergency Services, these services cannot be delayed until the Member can see a Plan Provider.

  • primary carer means the person who has responsibility for the care of the Child. Only one person can be the Child’s Primary Carer on a particular day.

  • Intensive Care Unit means an identified section, ward or wing of a hospital which is under the constant supervision of a dedicated medical practitioner(s), and which is specially equipped for the continuous monitoring and treatment of patients who are in a critical condition, or require life support facilities and where the level of care and supervision is considerably more sophisticated and intensive than in the ordinary and other wards.

  • Medically Necessary Treatment means any treatment, tests, medication, or stay in hospital or part of a stay in hospital which:

  • Emergency medical services personnel means that term as defined in section 20904 of the public health code, 1978 PA 368, MCL 333.20904.

  • Emergency Medical Technician (EMT means: an individual licensed with cognitive knowledge and a scope of practice that corresponds to that level in the National EMS Education Standards and National EMS Scope of Practice Model.

  • Outpatient means a person who is receiving care other than on an inpatient basis, such as: • in a provider’s office; • in an ambulatory surgical center or facility; • in an emergency room; or • in a clinic. .

  • Emergency medical technician means a person who is either an EMT-I, EMT-II, or EMT-P (paramedic), and possesses a valid certificate or license in accordance with the standards of Division 2.5 (commencing with Section 1797) of the Health and Safety Code.

  • Emergency medical services provider means a person who has received formal training in prehospital and emergency care, and is licensed to attend any person who is ill or injured or who has a disability. Police officers, firefighters, funeral home employees and other persons serving in a dual capacity one of which meets the definition of “emergency medical services provider” are “emergency medical services providers” within the meaning of this chapter.

  • Assisted outpatient treatment or "AOT" means the categories of outpatient services ordered by the court under section 468 or 469a. Assisted outpatient treatment may include a case management plan and case management services to provide care coordination under the supervision of a psychiatrist and developed in accordance with person-centered planning under section 712. Assisted outpatient treatment may also include 1 or more of the following categories of services: medication; periodic blood tests or urinalysis to determine compliance with prescribed medications; individual or group therapy; day or partial day programming activities; vocational, educational, or self-help training or activities; assertive community treatment team services; alcohol or substance use disorder treatment and counseling and periodic tests for the presence of alcohol or illegal drugs for an individual with a history of alcohol abuse or substance use disorder; supervision of living arrangements; and any other services within a local or unified services plan developed under this act that are prescribed to treat the individual's mental illness and to assist the individual in living and functioning in the community or to attempt to prevent a relapse or deterioration that may reasonably be predicted to result in suicide, the need for hospitalization, or serious violent behavior. The medical review and direction included in an assisted outpatient treatment plan shall be provided under the supervision of a psychiatrist.

  • Participating Hospice Care Program Provider means a Hospice Care Program Provider that either: (i) has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield to provide services to participants in this benefits program, or; (ii) a Hospice Care Program Provider which has been designated by a Blue Cross and/or Blue Shield Plan as a Participating Provider Option program.

  • Medically Appropriate means services and medical supplies required for prevention, diagnosis, or treatment of a physical or behavioral health condition or injuries that are:

  • Outpatient services means those services rendered in a practitioner’s office or in the department of an approved facility where services are rendered to persons who have not had an overnight stay and are not charged for room and board.

  • Medical Expense means an expense incurred at the time a past member or his or her health reimbursement account dependent is furnished the medical care or service. To be considered a medical expense under this act, the expense shall meet all of the following conditions:

  • Adolescent means a Medicaid patient 17 years or younger.