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Medical Necessity and Prior Authorization

 

Healthcare services, equipment, care, and supplies must be medically necessary to be covered. However, only services that are covered by SelectHealth will be eligible for reimbursement. Utah’s standard definition of "Medical Necessity" is as follows:

1. Healthcare services or products that a prudent healthcare professional would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is:

a. In accordance with generally accepted standards of medical practice in the United States;

b. Clinically appropriate in terms of type, frequency, extent, site, and duration;

c. Not primarily for the convenience of the patient, physician, or other health care provider; and

d. Covered under the contract.

2. When a medical question-of-fact exists, medical necessity shall include the most appropriate available supply or level of service for the individual in question, considering potential benefits and harms to the individual, and known to be effective.

a. For interventions not yet in widespread use, the effectiveness shall be based on scientific evidence.

b. For established interventions, the effectiveness shall be based on the following:

§  Scientific evidence,

§  Professional standards, and

§  Expert opinion.

It is the responsibility of the provider to determine medical necessity. However, the fact that a provider, even a participating provider may prescribe, order, recommend, or approve health care services, equipment, care, or supplies does not necessarily make it medically necessary, even if it is not listed as an exclusion or limitation. If you have questions, contact SelectHealth’s Member Services at 801-442-5038 (Salt Lake area) or 800-538-5038.

 

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