Friday, August 28, 2009

Medical necessity guidelines

Hmm! Look at this:

Coverage process-contractual definition of medical necessity, which includes the following criteria for establishing the medical necessity of a service: appropriate for symptoms, diagnosis, and treatment of a condition, illness, or injury; provided for diagnosis, direct care, or treatment; in accordance with the standards of good medical practice; not primarily for the convenience of the member or member's provider; the most appropriate supply or level of service that can be safely provided to the member. To determine what services meet this definition, Highmark has an information-gathering process that includes systematic reviews of published literature, a consulting program with practicing physicians, review of coverage decisions by Highmark managers, review by an independent Medical Affairs Committee.

This is a cut and paste from a site I Googled. Read the last sentence. Sounds like a constant review looking for ways or reasons to tighten a code. Kind of cold.

No comments:

Post a Comment