Medical Necessity
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Defines BCBSNC's definition of Medical Necessity and explains when services will be reimbursed under Blue Cross and Blue Shield of North Carolina; applies to providers and all product lines unless otherwise indicated.
No material clinical or coverage changes in this revision.
Medical Necessity — Coverage Criteria
Definition of Medical Necessity
Covered when ALL of the following are met
BCBSNC may compare cost-effectiveness of alternatives when determining coverage and setting.
Investigational, cosmetic, or other services that do not meet the definition of Medical Necessity are not covered and will not be reimbursed. Providers should confirm member benefits before rendering services, as coverage varies by benefit design.
Services that fail to meet all required elements of the policy’s Medical Necessity definition are not considered medically necessary and will not be covered. The Medical Necessity definition requires that all five criteria be met, including that the service be for diagnosis, treatment, cure, or relief of a health condition and be within generally accepted standards of medical care.
Applicable Service Codes
| No codes listed |
Provider Requirements, Prior Authorization, and Documentation
Prior authorization determined by procedure/service-specific rules
Prior authorization requirements are determined by procedure/service-specific rules; inclusion of a code in the policy does not guarantee reimbursement. BCBSNC may also request medical records to determine Medical Necessity.
- Inclusion of a code here does not guarantee reimbursement.
- Prior authorization determined by procedure/service-specific rules.
Confirm Medical Necessity and member benefits before providing service
If a service does not meet the definition of Medical Necessity, it will not be covered. Providers should verify member benefit language prior to service because benefits may vary by plan.
- The fact that a doctor orders a service does not by itself make it medically necessary; only the member’s medical condition is considered.
- This policy applies to all product lines unless otherwise indicated; review the Member’s Benefit Booklet for benefit availability.
Provide complete medical records when requested; letters alone may be insufficient
BCBSNC may request medical records to determine Medical Necessity; when records are requested, letters of support or explanation may be useful but are insufficient unless they include all specific information needed for the Medical Necessity determination.
- Provide complete medical records when requested.
- If submitting letters of support/explanation, ensure they contain all specific information required to make a Medical Necessity determination.
Denial triggers: not medically necessary, investigational, or cosmetic services
Services that do not meet BCBSNC’s definition of Medical Necessity or are investigational, cosmetic, or not covered under the member’s benefit plan will not be covered and will not be reimbursed.
- Investigational, cosmetic, or other services that do not meet the definition of Medical Necessity are not covered.
- Services failing to meet all required Medical Necessity criteria are not considered medically necessary and will not be covered.
Policy Background
This corporate medical policy defines Medical Necessity for Blue Cross and Blue Shield of North Carolina and establishes that services must be for the diagnosis, treatment, cure, or relief of a health condition, illness, injury, or disease. The policy specifies five required criteria that must all be met for a service to be considered medically necessary, including that the service is not experimental, investigational, or cosmetic (except as allowed under North Carolina law) and that it conforms to generally accepted standards of medical care.
Key Definitions
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