Medically Necessary Services definition
Medically Necessary Services means those covered services that are, under the terms and conditions of the contract, determined through contractor utilization management to be:
Medically Necessary Services. With respect to the Medicaid and/or Medical Assistance Programs (MAP), “Medical Necessity” or “Medically Necessary Services” are those services or supplies necessary to prevent, diagnose, correct, prevent the worsening of, alleviate, ameliorate, or cure a physical or mental illness or condition; to maintain health; to prevent the onset of an illness, condition, or disability; to prevent or treat a condition that endangers life or causes suffering or pain or results in illness or infirmity; to prevent the deterioration of a condition; to promote the development or maintenance of maximal functioning capacity in performing daily activities, taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age; to prevent or treat a condition that threatens to cause or aggravate a handicap or cause physical deformity or malfunction, and there is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the enrollee. The services provided, as well as the type of provider and setting, must be reflective of the level of services that can be safely provided, must be consistent with the diagnosis of the condition and appropriate to the specific medical needs of the enrollee and not solely for the convenience of the enrollee or provider of service and in accordance with standards of good medical practice and generally recognized by the medical scientific community as effective. A course of treatment may include mere observation or where appropriate no treatment at all. Experimental services or services generally regarded by the medical profession as unacceptable treatment are not Medically Necessary Services for purposes of this Agreement. Medically Necessary Services provided must be based on peer-reviewed publications, expert pediatric, psychiatric, and medical opinion, and medical/pediatric community acceptance. In the case of pediatric Members/enrollees, the definition herein shall apply with the additional criteria that the services, including those found to be needed by a pediatric Member as a result of a comprehensive screening visit or an inter-periodic encounter, whether or not they are ordinarily Covered Services for all other Medicaid Members are appropriate for the age and health status of the individual, and the service will aid the overall physical and mental growth and development of the individual, and the s...
Medically Necessary Services means a requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent worsening of conditions in the Individual that endanger life, cause suffering of pain, result in an illness or infirmity, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the client requesting the service. “Course of treatment" may include mere observation or, where appropriate, no treatment at all.
Examples of Medically Necessary Services in a sentence
PROVIDER shall accept consumers referred and shall render Medically Necessary Services, which PROVIDER is qualified by law to render, customarily provides, and has the capacity to provide.
The Contractor may not structure compensation to individuals or utilization management entities so as to provide inappropriate incentives for the individual or entity to deny, limit, or discontinue Medically Necessary Services to any Member.
Those Medically Necessary Services and supplies set forth in this Certificate, which are covered subject to all of the terms and conditions of the Group Agreement and Certificate.
The Contractor shall refer Members to Providers enrolled in the Medicaid Fee-for- Service delivery system for all Medically Necessary Services not covered by the Contractor under the MississippiCAN Program.
Shall be defined as Medically Necessary Services, that are not specifically excluded from coverage by this Agreement and other Services which are specifically included.
More Definitions of Medically Necessary Services
Medically Necessary Services means that the service or benefit is:
a. Directly related to diagnostic, preventive, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition;
b. Consistent with current accepted standards of good medical practice;
c. The most cost-efficient service that can be provided without sacrificing effectiveness or access to care; and
d. Not primarily for the convenience of the consumer, the consumer's family, or the provider.
Medically Necessary Services. As defined by the Social Security Act, Section 1905 (42 USC 1396d(a)), the State Plan, and Administrative Code, Medically Necessary Services are also the most appropriate services that help achieve age-appropriate growth and development and will allow a Member to attain, maintain, or regain capacity. Medically Necessary Services may also be those services for Members that are necessary to correct or ameliorate disorders and physical and behavioral/mental illnesses and conditions, whether such services are covered or exceed the benefit limits in the Medicaid State Plan and Title 23 of Mississippi Administrative Code.
Medically Necessary Services means health care services for the purpose of evaluating, diagnosing, or treating an illness, injury, or disease in accordance with Generally Accepted Standards of Medical Practice.
Medically Necessary Services means services or supplies provided by an institution, physician, or other providers that are required to identify or treat a beneficiary's illness, disease, or injury and which are:
Medically Necessary Services. As set forth in the Social Security Act, Section 1905 (42 USC 1396d(a)), Medically Necessary Services are defined as services, supplies, or equipment provided by a licensed health care professional that are:
1. Appropriate and consistent with the diagnosis or treatment of the Covered Person’s condition, illness, or injury;
2. In accordance with the standards of good medical practice consistent with the individual Covered Person’s condition(s);
3. Not primarily for the personal comfort or convenience of the Member, family, or Provider;
4. The most appropriate services, supplies, equipment, or levels of care that can be safely and efficiently provided to the Covered Person;
5. Furnished in a setting appropriate to the Covered Person’s medical need and condition and, when applied to the care of an inpatient, further mean that the Covered Person’s medical symptoms or conditions require that the services cannot be safely provided to the Covered Person as an outpatient;
6. Not experimental or investigational or for research or education;
7. Provided by an appropriately licensed practitioner; and
8. Documented in the patient's record in a reasonable manner, including the relationship of the diagnosis to the service. Medically Necessary Services may also be those services for children that are necessary to correct or ameliorate defects and physical and mental illnesses and conditions discovered during an interperiodic or periodic EPSDT screen, whether such services are covered or exceed the benefit limits in the Medicaid State Plan and Title 23 of Mississippi Administrative Code.
Medically Necessary Services means medical services necessary to protect life, to prevent 25 significant disability or to prevent serious deterioration of health.
Medically Necessary Services means the meaning as defined by CMS as services of items reasonable and necessary for the diagnosis or treatment of illness or injury and are Services not included in the list of “particular services excluded from coverage” in 42 CFR § 411.15.