The principle that healthcare services and treatments provided to patients must be appropriate and necessary for the diagnosis or treatment of their medical conditions. It is determined based on established medical standards and evidence-based practices.
The extent to which an insurance policy pays for medical services, including those deemed medically necessary. Coverage may vary based on the terms of the policy and the determination of medical necessity.
A process by which healthcare providers obtain approval from insurance companies before providing certain medical services or treatments. Preauthorization ensures that the services are medically necessary and covered by the patient’s insurance plan.
A systematic assessment of the appropriateness and necessity of healthcare services, including those related to medical necessity. Utilization review helps insurance companies determine whether the services provided meet established criteria and guidelines.
Evidence-based recommendations for healthcare providers regarding the diagnosis, treatment, and management of various medical conditions. Clinical guidelines often play a crucial role in determining medical necessity and insurance coverage.
The refusal by an insurance company to pay for certain medical services or treatments, typically due to a determination that they are not medically necessary. Denials may be appealed by healthcare providers or patients if they believe the services are justified.
A formal procedure for challenging a denial of coverage by an insurance company. Healthcare providers or patients can submit additional information or evidence to support the medical necessity of the denied services during the appeals process.
Specific standards or criteria used by insurance companies to evaluate the medical necessity of healthcare services. These criteria may include factors such as the patient’s diagnosis, symptoms, and treatment history.
The excessive or unnecessary use of healthcare services, including tests, procedures, or treatments, which may not be medically justified. Insurance companies may implement strategies to address overutilization and ensure that resources are allocated appropriately.
The process by which an insurance company evaluates whether a particular healthcare service or treatment is covered under a patient’s insurance policy. Benefit determinations often involve assessing the medical necessity of the requested services in accordance with the terms of the policy.