Medical Necessity Sample Clauses

Medical Necessity. We Cover benefits described in this Contract as long as the dental service, procedure, treatment, test, device, or supply (collectively, “service”) is Medically Necessary e.g. orthodontia. The fact that a Provider has furnished, prescribed, ordered, recommended, or approved the service does not make it Medically Necessary or mean that We have to Cover it. We may base Our decision on a review of: • Your dental records; • Our dental policies and clinical guidelines; • Dental opinions of a professional society, peer review committee or other groups of Physicians; • Reports in peer-reviewed dental literature; • Reports and guidelines published by nationally-recognized health care organizations that include supporting scientific data; • Professional standards of safety and effectiveness, which are generally-recognized in the United States for diagnosis, care, or treatment; • The opinion of health care professionals in the generally-recognized health specialty involved; • The opinion of the attending Providers, which have credence but do not overrule contrary opinions. Services will be deemed Medically Necessary only if: • They are clinically appropriate in terms of type, frequency, extent, site, and duration, and considered effective for Your illness, injury, or disease; • They are required for the direct care and treatment or management of that condition; • Your condition would be adversely affected if the services were not provided; • They are provided in accordance with generally-accepted standards of dental practice; • They are not primarily for the convenience of You, Your family, or Your Provider; • They are not more costly than an alternative service or sequence of services, that is at least as likely to produce equivalent therapeutic or diagnostic results; • When setting or place of service is part of the review, services that can be safely provided to You in a lower cost setting will not be Medically Necessary if they are performed in a higher cost setting. See the Utilization Review and External Appeal sections of this Contract for Your right to an internal Appeal and external appeal of Our determination that a service is not Medically Necessary.
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Medical Necessity. In order for Health Care Services to be covered under this Contract, such services must meet all of the requirements to be a Covered Benefit or Covered Service, including being Medically Necessary, as defined by AvMed.
Medical Necessity. 6.1. CONTRACTOR will ensure that services provided are medically necessary in compliance with BHIN 21-073 and pursuant to Welfare and Institutions Code section 14184.402(a). Services provided to a client must be medically necessary and clinically appropriate to address the client’s presenting condition. Documentation in each client’s chart as a whole will demonstrate medical necessity as defined below, based on the client’s age at the time of service provision.
Medical Necessity. Unless otherwise stated in the Agreement, the ben- efits of this Agreement are provided only for Ser- vices which are medically necessary.
Medical Necessity. 4.5.4.1 Based upon generally accepted medical practices in light of Conditions at the time of treatment, Medically Necessary services are those that are: · Appropriate and consistent with the diagnosis of the treating Provider and the omission of which could adversely affect the eligible Member’s medical Condition; · Compatible with the standards of acceptable medical practice in the community; · Provided in a safe, appropriate, and cost-effective setting given the nature of the diagnosis and the severity of the symptoms; · Not provided solely for the convenience of the Member or the convenience of the Health Care Provider or hospital; and · Not primarily custodial care unless custodial care is a covered service or benefit under the Members evidence of coverage.
Medical Necessity. The definition of medical necessity for Medicaid services is included in the Michigan Medicaid Provider Manual: Mental HealthSubstance Abuse section.
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Medical Necessity. 4.5.4.1 Based upon generally accepted medical practices in light of Conditions at the time of treatment, Medically Necessary services are those that are:
Medical Necessity. As defined in Hawaii Revised Statutes (“HRS”) 432E-1.4, for health interventions that the health plans are required to cover within the specified categories, a health intervention is medically necessary if it is recommended by the treating physician or treating licensed health care provider, is approved by health plan’s medical director or physician designee, and is:
Medical Necessity. The Utilization Management (UM) program, processes and timeframes shall be in accordance with 00 XXX 000, 00 XXX 000, 00 XXX 438 and the private review agent requirements of KRS 304.17A as applicable. The Contractor shall have a comprehensive UM program that reviews services for Medical Necessity and that monitors and evaluates on an ongoing basis the appropriateness of care and services for physical and behavioral health. A written description of the UM program shall outline the program structure and include a clear definition of authority and accountability for all activities between the Contractor and entities to which the Contractor delegates UM activities. The description shall include the scope of the program; the processes and information sources used to determine service coverage; clinical necessity, appropriateness and effectiveness; policies and procedures to evaluate care coordination, discharge criteria, site of services, levels of care, triage decisions and cultural competence of care delivery; processes to review, approve and deny services, as needed, particularly but not limited to the EPSDT program. The UM program shall be evaluated annually, including an evaluation of clinical and service outcomes. The UM program evaluation along with any changes to the UM program as a result of the evaluation findings, will be reviewed and approved annually by the Medical Director, the Behavioral Health Director, or the Medicaid Commissioner.
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