Understanding medical necessity in health care

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The two keys to achieving better health outcomes

Medical Necessity

Services must be consistent with the standards of good medical practice and not primarily for the convenience of the member or provider.

Key components include:

  • Be appropriate for the diagnosis or treatment of a condition
  • Be provided in accordance with accepted standards of medical practice
  • Be the most appropriate level of service that can be safely provided
  • Convenience over necessity should not be a factor in determining care.

Clinically Appropriate Care

Care that is based on clinical guidelines, evidencebased practices, and the professional judgment of health care providers.

Key components include:

  • Evidence-based: Care that is supported by scientific research and clinical guidelines
  • Person-centered: : Tailored to the individual needs and preferences of the member
  • Effective: Proven to achieve the desired health outcomes
  • Efficient: Delivered in a manner that maximizes resource use without compromising quality

Importance in Enhancing the Health care Experience

  • Cost-Effectiveness: Prevents unnecessary treatments and procedures, reducing healthcare costs.
  • Patient Safety: Minimizes the risk of harm by avoiding unnecessary or inappropriate interventions.
  • Insurance Coverage: Many insurance plans require that services be medically necessary to be covered.

For more information or to schedule a visit with an EAP counselor

To schedule a visit with an EAP counselor, please visit bhoptions.eapintake.com. You can also schedule a visit in-person or by phone by calling Behavioral Healthcare Options at 1-800-280-3782, TTY 711. 

You have the right to receive help and information in your language at no cost. To request an interpreter, call the toll-free member number on your plan ID card or plan documents.