Medically Necessary Care. 1. With respect to services other than mental health services: This is diagnostic testing and medical treatment and prescription drug use which is medically appropriate to your physical diagnosis for an injury or illness, and preventive services covered in this SPD. Medically necessary care must meet the following criteria: • it meets clinically accepted medical services and practice parameters of the general medical community; and • it meets the most appropriate and cost-effective level of medical services, prescription drugs or supplies that can be safely provided. When applied to inpatient care, it further means that the medical symptoms or conditions require that the medical services or supplies cannot be safely provided in a lower level of care setting; and • it restores or maintains health; or • it prevents deterioration of your condition; or • it prevents the reasonably likely onset of a health problem or detects an incipient problem. To be considered medically necessary care, it must not be maintenance or custodial care, or ineffective care, or otherwise excluded under this SPD. The fact that an authorized Network, or Non-Network, Provider prescribes treatment does not necessarily mean the treatment is covered under this Plan.
Medically Necessary Care. Nothing in this Agreement shall be construed to provide any payment or reimbursement provision creating an inducement for Provider to withhold medically necessary care to Members. Nothing in this paragraph shall be construed to prohibit the use of payment arrangements between UBH and Provider involving capitation, withholds or other arrangements. Nothing in this paragraph shall be construed to prohibit health care carriers from providing coverage for only those services which are medically necessary and subject to the terms and conditions of the Member’s policy.
