Coverage for services may vary due to federal and state mandates, laws, rules, and regulations. The laws of the state where the benefit contract is issued determine the applicable mandated coverage.
Please refer to the member's benefit booklet for the definition of medically necessary.
The following general principles are the basis for the Company's determination that a service is medically necessary:
- The service that an appropriate provider, exercising prudent clinical judgement, provides a member is appropriate and effective for preventing, evaluating, diagnosing, or treating an illness, injury, disease or its symptoms for which it is prescribed or performed, and not for experimental/investigational or cosmetic purposes; AND
- The service is clinically appropriate, in terms of type, frequency, extent, and site and duration, and is considered effective for the member's illness, injury, or disease; AND
- The service is appropriate with regard to generally accepted standards of medical practice within the medical community; AND
- The service is not primarily for the convenience of the member, the member's family, the professional provider, or other health care provider; AND
- The service is not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the member's illness, injury, or disease.
For these purposes, "generally accepted standards of medical practice" takes into consideration:
- Standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community;
- Physician specialty society recommendations;
- The views of professional providers practicing in the relevant clinical area; and
- Any other relevant factors.
Coverage is not available for services that do not meet the definition of medically necessary, including, but not limited to, experimental/investigational, cosmetic, and/or not medically necessary services.
When there is a Company medical policy addressing a specific item or service, refer to the applicable policy.
In the absence of coverage criteria from a medical policy document setting forth coverage criteria, the Company will apply the definition of medical necessity, in consideration of defined plan benefits, benefit limits and in accordance with generally accepted standards of medical practice, to determine whether a service can be considered medically necessary.
FAILURE TO USE DESIGNATED PROVIDER
HEALTH MAINTENANCE ORGANIZATION (HMO) and HMO POINT-OF-SERVICE (HMO-POS)
HMO and HMO Point-of-Service (HMO-POS) products may require that the member obtain certain 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.
