Common use of Services Not Medically Necessary Clause in Contracts

Services Not Medically Necessary. This agreement does NOT cover hospital care (admission tests, services, supplies, or continued care), medical care, behavioral health services, rehabilitation, or any other treatment, procedure, facility, equipment, drug, device, supply or service which is NOT medically necessary. We will use any reasonable means to make a determination about the medical necessity of this care. We may look at medical records, reports and utilization review committee statements. We review medical necessity in accordance with our medical policies and related guidelines. You have the right to appeal our determination or to take legal action as described in Section 7.0. We may deny payments if a doctor or hospital does not supply medical records needed to determine medical necessity. We may also deny or reduce payment if the records sent to us do not provide adequate justification for performing the service. This agreement does NOT cover routine screenings or tests performed by a hospital which are not medically necessary for the diagnosis or treatment of your condition. This agreement does NOT cover routine screenings or tests which are not specifically ordered by the doctor who admits you.

Services Not Medically Necessary. This agreement does NOT cover hospital care (admission tests, services, supplies, or continued care), medical care, behavioral health services, rehabilitation, or any other treatment, procedure, facility, equipment, drug, device, supply or service which is NOT medically necessary. We will use any reasonable means to make a determination about the medical necessity of this care. We may look at medical hospital records, reports and hospital utilization review committee statements. We review medical necessity in accordance with our medical policies and related guidelines. You have the right to appeal our determination or to take legal action as described in Section 7.0. We may deny payments if a doctor or hospital does not supply medical records needed to determine medical necessity. We may also deny or reduce payment if the records sent to us do not provide adequate justification for performing the service. This agreement does NOT cover routine screenings or tests performed by a hospital which are not medically necessary for the diagnosis or treatment of your condition. This agreement does NOT cover routine screenings or tests which are not specifically ordered by the doctor who admits you.

Services Not Medically Necessary. This agreement does NOT cover hospital care (admission tests, services, supplies, or continued care), medical care, behavioral health services, rehabilitation, or any other treatment, procedure, facility, equipment, drug, device, supply or service which is NOT medically necessary. We will use any reasonable means to make a determination about the medical necessity of this care. We may look at medical records, reports and utilization review committee statements. We review medical necessity in accordance with our medical policies and related guidelines. You have the right to appeal our determination or to take legal action as described in Section 7.0. We may deny payments if a doctor or hospital does not supply medical records needed to determine medical necessity. We may also deny or reduce payment if the records sent to us do not provide adequate justification for performing the service. This agreement does NOT cover routine screenings or tests performed by a hospital hospital, which are not medically necessary for the diagnosis or treatment of your condition. This agreement does NOT cover routine screenings or tests tests, which are not specifically ordered by the doctor who admits you.