Medical Necessity and Appropriateness Sample Clauses

Medical Necessity and Appropriateness. Members will receive designated benefits under the Contract only when medically necessary and appropriate. HMO may determine whether any benefit provided under the Contract was medically necessary and appropriate, and HMO has the option to select the appropriate Participating Hospital to render services if hospitalization is necessary. Decisions as to medical necessity are subject to review by the Quality Assurance Committee of HMO or its physician designee. HMO will not, however, seek reimbursement from an eligible Member for the cost of any benefit provided under the Contract that is later determined to have been medically unnecessary and inappropriate, when such service is rendered by the primary care physician or a provider referred by the primary care physician without notifying the member that such benefit would not be covered under the contract.
Sample 1
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Related to Medical Necessity and Appropriateness

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