 |
This Web site is a component of the SAMHSA Health Information Network. |
|
Medical Necessity in Private Health Plans
Figure 4: Common Procedural Problems in Medical Necessity Determination Processes Noted in Investigations, Litigation, and Case Law
- Decision made in arbitrary or capricious manner without consideration of individual patient needs
- Decision made inconsistently (i.e., some patients' claims denied while others in equivalent circumstances
approved)
- Claims reviewers unqualified or not appropriately trained
- Application of arbitrary and unreasonable caps on coverage and/or dollar limits
- Insufficient information provided in claims denials:
- No disclosure of clinical rationale used in making decision
- No disclosure of qualifying credentials of reviewer
- No disclosure of evidence or documentation used in decision
- No description of the procedures, timeframes, and consumer rights for grievance and appeal
- Failure to consult with treating physician
- Failure to consider medical evidence provided by patient
- Failure to provide full and fair review to patient appealing claims denial
- Lack of clarity and specificity in plan documents of excluded services (e.g., definitions of "experimental,"
"convenience")
- Conflict of interest of MCO decisionmaker that biased impartial judgment
|
Table of Contents | Previous | Next
|
|
