Health insurance companies use medical necessity criteria as tools to assist in clinical decision-making. Though doctors and other health care providers drive decisions about your care, many procedures, specialist visits, tests, hospitalizations, surgeries, behavioral health and substance abuse treatment requires authorization from your insurance company. The companies issue a determination that results in an approval or denial of services and claims. Medical necessity criteria provide guidelines in making these determinations.
What is Medical Necessity Criteria?
Medical necessity criteria are sets of guidelines used by health professionals to determine the medical necessity of care. Insurance companies use these guidelines as a basis for decisions to approve or deny care. Guidelines help clinicians make decisions about length of hospital stays and appropriateness of procedures, tests, treatment and other care. While some health insurance companies establish their own criteria, others use existing criteria such as Milliman Care Guidelines and InterQual. All criteria are clinically evidence-based, reviewed and updated annually, and thoroughly researched.
Criteria Usage
Health insurance companies use care criteria tools to make decisions, recommendations about limitations and treatment options. While routine care does not typically need review, requests for pre-authorization of services and hospitals stays are reviewed for medical necessity. Providers must submit a request for authorization to the insurance company for review. The insurance company determines if the request meets medical necessity and makes a decision to approve or denial the surgery. Additionally, when a member is hospitalized, the hospital staff contacts the insurance company to obtain authorization for continued stay. The care is reviewed for medical necessity and the insurance company decides how many days should be approved, if any.
Review Process
Health professionals such as nurses, doctors, social workers and other clinicians complete care reviews and make recommendations. They review the treatment plans submitted by providers and compare them to medical necessity criteria to guide their decisions. Criteria are often integrated with the insurance company's software programs for easy viewing and selection. The reviewer uses a criteria checklist, programmed into the system, to review and select criteria to determine the appropriateness of care. This allows for easy documentation of approvals and denials.
Appealing a Denial
All health insurance plans offer the right to appeal a denial of services or care. The health plan member, provider or member's representative can file an appeal. Health plans offer at least one level of appeal and many offer up to three, including an external final level, using non-health plan employees as reviewers. To initiate an appeal, the appealer must call the health plan or send a written request for an appeal review. Reviewers who have had no prior input of the original decisions conduct each subsequent review.
Tags: insurance company, medical necessity, criteria tools, decisions about, denial services, health insurance
