The Company provides coverage for those covered services that are determined to be medically necessary consistent with benefit contracts and medical policy.
The definition of medically necessary can be found in the member's plan design. Please refer to the member's specific plan design for the definition of medically necessary.
Coverage is not available for services that do not meet the definition of medical necessary, including, but not limited to, experimental/investigational, cosmetic, and/or not medically necessary services.
When there is a Company policy addressing a specific item or service, refer to the applicable policy. The information in the specific policy takes precedence over this general policy. The medical necessity requirements and limitations listed in those policies apply.
FAILURE TO USE DESIGNATED PROVIDER
HEALTH MAINTENANCE ORGANIZATION (HMO)
HMO and HMO Point-of-Service (HMO-POS) products may require that the member obtain medically necessary services (e.g., Laboratory, Radiology) at the primary care provider’s (PCP’s) designated provider. In most cases, services that are rendered at a nondesignated provider for members enrolled in HMO or HMO-POS products are not eligible for reimbursement consideration by the Company, with certain exceptions (e.g., medically necessary service cannot be provided at the designated provider).
OUT-OF-NETWORK SERVICES
HMO and HMO POINT-OF-SERVICE (HMO-POS)
In most cases, services received from an out-of-network provider (a provider who is not part of the Plan's network) will not be covered. However, services received from an out-of-network provider will be eligible for reimbursement consideration when the services are determined to be covered by the Plan and medically necessary and the Plan's in-network providers are unable to provide these services, or there are no providers within statutorily required distance requirements who can provide the service.
Services that are considered not covered by the Plan will not be eligible for reimbursement consideration. The following are some examples of services that are not eligible for reimbursement consideration: experimental/investigational services, cosmetic services, and durable medical equipment for comfort and convenience.
Once the service has been determined to be a covered service by the Plan and medically necessary, the Plan will determine if there is a provider or choice of providers within the plan’s network with the capacity to perform the requested service. This review will consider applicable state distance regulations. In the event that there is more than one network provider with capacity to perform the service, the plan will provide a choice of network providers to the requestor.
PREFERRED PROVIDER ORGANIZATION (PPO)
Services may be received from an out-of-network provider and will be eligible for reimbursement consideration when determined to be covered by the Plan and medically necessary. However, if an out-of-network provider is used, the member's out-of-pocket costs for covered services may be higher.
PLACE OF SERVICE
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
REQUIRED DOCUMENTATION
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.
The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
