Common use of Medically Necessary and Appropriate Clause in Contracts

Medically Necessary and Appropriate. “Medically necessary and appropriate” means that the benefits under the Agreement for services received from a network provider will be provided only when and so long as such services are determined by the Plan to be: a) appropriate for the symptoms and diagnosis or treatment of the member’s condition, illness, disease or injury; and b) provided for the diagnosis, or the direct care and treatment of the member’s condition, illness, disease or injury; and c) in accordance with standards of good medical practice; and d) not primarily for the convenience of the member, or the member’s physician and/or other provider; and e) the most appropriate supply or level of service that can safely be provided to the member. When applied to hospitalization, this further means that the member requires acute care as an inpatient due to the nature of the services rendered or the member’s condition, and the member cannot receive safe or adequate care as an outpatient. Network facility providers and preferred professional providers will accept this determination of medical necessity. Out-of-network providers are not obligated to accept this determination and may ▇▇▇▇ the member for services determined not to be medically necessary and appropriate. See the Agreement for further explanation.

Medically Necessary and Appropriate. “Medically “Medically necessary and appropriate” appropriate” means that the benefits under the Agreement for services received from a network provider will be provided only when and so long as such services are determined by the Plan to be: a) appropriate for the symptoms and diagnosis or treatment of the member’s member’s condition, illness, disease or injury; and b) provided for the diagnosis, or the direct care and treatment of the member’s member’s condition, illness, disease or injury; and c) in accordance with standards of good medical practice; and d) not primarily for the convenience of the BSMUHDHP1200-O member, or the member’s member’s physician and/or other provider; and e) the most appropriate supply or level of service that can safely be provided to the member. When applied to hospitalization, this further means that the member requires acute care as an inpatient due to the nature of the services rendered or the member’s member’s condition, and the member cannot receive safe or adequate care as an outpatient. Network facility providers, network professional providers and preferred PremierBlue Shield professional providers (out-of-area) will accept this determination of medical necessity. Out-of-network providers are provide▇▇ ▇re not obligated to accept this determination and may ▇▇▇▇ bill the member for services determined not to be medically necessary and appropriate. See the Agreement for further explanation.

Medically Necessary and Appropriate. “Medically necessary and appropriate” means that the benefits under the Agreement for services received from a network provider will be provided only when and so long as such services are determined by the Plan to be: a) appropriate for the symptoms and diagnosis or treatment of the member’s condition, illness, disease or injury; and b) provided for the diagnosis, or the direct care and treatment of the member’s condition, illness, disease or injury; and c) in accordance with standards of good medical practice; and d) not primarily for the convenience of the member, or the member’s physician and/or other provider; and e) the most appropriate supply or level of service that can safely be provided to the member. When applied to hospitalization, this further means that the member requires acute care as an inpatient due to the nature of the services rendered or the member’s condition, and the member cannot receive safe or adequate care as an outpatient. Network facility providers and preferred professional providers will accept this determination of medical necessity. Out-of-network providers are not obligated to accept this determination and may ▇▇▇▇ bill the member for services determined not to be medically necessary and appropriate. See the Agreement for further explanation.