Medical Necessity Determination. 2.6.3.1 The CONTRACTOR may establish procedures for the determination of medical necessity. The determination of medical necessity shall be made on a case by case basis and in accordance with the definition of medical necessity defined in TCA 71- 5-144 and TennCare rules and regulations. However, this requirement shall not limit the CONTRACTOR’s ability to use medically appropriate cost effective alternative services in accordance with Section 2.6.5.
Medical Necessity Determination. The Contractor shall determine which services are medically necessary, according to utilization management requirements and the definition of Medically Necessary Services in this Contract. The Contractor’s determination of medical necessity in specific instances shall be final except as specifically provided in this Contract regarding appeals, hearings and independent review.
Medical Necessity Determination. Health Plan’s determination with regard to Medically Necessary services and scope of Covered Services, including determinations of level of care and length of stay benefits available under the Member’s health program shall govern. The primary concern with respect to all medical determination shall be in the interest of the Member.
Medical Necessity Determination. 3.4.5.1 The Contractor shall provide Covered Services consistent with the State’s definition of Medical Necessity, as provided below.
Medical Necessity Determination. 2.6.3.1 The CONTRACTOR may place appropriate limits on a covered benefit. In accordance with the TennCare medical necessity rule, the CONTRACTOR may establish procedures for the determination of medical necessity and for the use of medically appropriate cost effective alternative benefits. The CONTRACTOR may also limit benefits for the purpose of utilization control in accordance with NCQA standards, as long as (1) the furnished benefits can reasonably achieve the purpose for which they are furnished, and as long as (2) the benefits furnished for enrollees with chronic conditions (or who require LTSS) are authorized in a manner that reflects the enrollee’s ongoing need for such benefits. See 42 C.F.R. §438.3(e)(2) and 42 C.F.R. §438.210(a)(4). Additionally, the CONTRACTOR shall include in its review of medical necessity for CHOICES or ECF CHOICES HCBS and HCBS- related services, including Durable Medical Equipment, for individuals receiving HCBS in CHOICES, ECF CHOICES, or a Section 1915(c) HCBS Waiver, whether the HCBS or related service provide an opportunity for the member receiving long- term services and supports to have access to the benefits of community living, achieve person-centered goals, be free of undue restraint, and live and work in the setting of their choice as prescribed in TennCare policy.
Medical Necessity Determination. Health Plan’s determination regarding Medical Necessity, including, but not limited to, determinations of level of care and length of stay, will govern.
Medical Necessity Determination. Standard Review: In the event that an Appeal of an Adverse Benefit Determination is based in whole or in part on Medical Necessity, and the Insured is not satisfied with the outcome of the Appeal review process as explained in this section of the Certificate, the Insured has the right, but not the obligation, to submit the Appeal to external review. External review Appeals are conducted by independent review organizations (IROs), selected by the Nevada Office for Consumer Health Assistance (OCHA). Except when agreed upon by both parties, or when we fail to follow the established appeals procedure as described above, the internal review process must be exhausted before an Appeal can be submitted for external review. The Health Plan will pay for the costs of the external review, including filing, administrative, and reviewer fees. Any statute of limitations or other defense based on timeliness will not be counted during the time that an external review is pending. All requests for external review must be made within four (4) months from the date the Adverse Benefit Determination is received. To request an external review, the Insured, treating Physician, or Insured’s representative must complete and submit on the appropriate forms a request for external review of the Adverse Benefit Determination to OCHA. The Insured or Insured’s representative must also complete an authorization form allowing the Health Plan and the treating Physician/health care providers to disclose the Insured’s protected health information (PHI), including medical records, which are pertinent to the external review. Within five (5) business days after receiving a request for external review, OCHA will notify the Insured, treating Physician, Insured’s representative, and the Health Plan that the request has been filed with OCHA. OCHA will assign an IRO to conduct the review. Within five (5) business days after receiving notification from OCHA specifying the designated IRO, the Health Plan will forward all relevant information to the IRO. Within five (5) calendar days after receiving information from the Health Plan, the IRO may request additional information as necessary. Information requested from the Insured must be provided within five (5) calendar days after receiving notice that it is required to conduct the review. The IRO must submit any additional information received to the Health Plan within one (1) business day of its receipt. Once all required information is received, the IRO...
