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Medically Necessary Care

The Medical Plan covers only those expenses the Claims Administrator determines to be medically necessary. Medically necessary services are services that are reasonable and necessary to diagnose and treat an illness or injury at the appropriate level of care. Medically necessary covered services are those services and supplies that are determined to satisfy all of the following criteria:

  • Delivered in a quantity that is no more than is required to meet your basic health needs;
  • Consistent with the diagnosis of the condition for which they are required;
  • Required for purposes of the medical treatment and not for the comfort or convenience of the patient or physician;
  • Rendered in the least intensive setting that is appropriate for the delivery of the required health care; and
  • Of demonstrated medical value.

The evaluation of whether medical treatment is medically necessary is applied to the entire episode of care and not to the separate segments of care. An episode of care is the period beginning with the first interaction of the medical provider and the patient. It continues during the treatment of the illness or injury and ends with any support that the Claims Administrator’s contracted agencies provide to assist the patient in returning to normal activities of daily life in which further medical intervention is not required.

In all circumstances, each Claims Administrator will condition coverage on its determination that the treatment meets the specific Plan requirements and has full discretionary authority to rely on its own materials, expertise and procedures.