CurrentSelectHealthPolicy N/A

Medical Necessity — Geographic Considerations

Defines how geographic location may be considered when determining medical necessity for SelectHealth members across Commercial, Medicare (Select Health Advantage), and Medicaid/CHIP (Select Health Community Care) plans.

Policy Summary

PayerSelectHealth

PolicyMedical Necessity — Geographic Considerations

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 24, 2024

Next Review DateN/A

Key ActionObtain preauthorization and submit all facts and circumstances when geographic location is a factor in the medical necessity determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3plan lines

1policies

4/24/24implementation

Geographic Considerations in Medical Necessity

Commercial Plan policy

Consideration of geographic location in medical necessity determinations

Commercial Plan geographic consideration: If the criteria for determining medical necessity consider the geographic location of the services as a factor, then all facts and circumstances relevant to the medical necessity determination shall be considered in evaluating whether the particular member would benefit from services in a particular geographic location.

Does not create entitlement to in‑network coverage for out‑of‑network services (i.e., 'failed access').

Medicare and Medicaid alignment

Applicability to other lines of business

Select Health Advantage and Select Health Community Care: Select Health Advantage (Medicare/CMS) and Select Health Community Care (Medicaid/CHIP) will follow the Commercial Plan Policy regarding consideration of geographic location when determining medical necessity.

Commercial Plan policy states that geographic benefit is not an entitlement to in‑network coverage for out‑of‑network services (i.e., 'failed access').

Policy Summary

PayerSelectHealth

PolicyMedical Necessity — Geographic Considerations

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 24, 2024

Next Review DateN/A

Key ActionObtain preauthorization and submit all facts and circumstances when geographic location is a factor in the medical necessity determination.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization required. Preauthorization is required before the member receives services. When a prior authorization request is reviewed, determinations of medical necessity will be made and may include consideration of the geographic location where services are to be provided.

Applies to services for which geographic location is an applicable factor in medical-necessity review
Providers must request authorization before delivering services

Documentation Required

High-Importance Provider Action

Provider action — high importance. When geographic location is a factor, submit a complete preauthorization request with all relevant facts and documentation so the reviewer can evaluate medical necessity in context.

Include clinical rationale, location of proposed services, availability of in-network alternatives, and any access issues
Incomplete requests may delay review or result in denial

Documentation Required

Submit Full Facts and Circumstances

Submit full facts and circumstances for preauthorization. When geographic location is considered, the reviewer will evaluate all facts and circumstances relevant to whether the member would benefit from services in that location — providers must supply those facts as part of the authorization request.

Document why services must be provided at the specified location
Provide evidence of local availability, provider network status, and any travel or access barriers

Denial Risk

Geographic Benefit ≠ In‑Network Coverage

Geographic benefit does not guarantee in‑network coverage. A determination that a member might benefit from services in a particular geographic location is not an entitlement to in‑network coverage for out‑of‑network services (i.e., a benefit finding is not the same as "failed access").

Authorization or medical-necessity finding ≠ automatic in-network coverage for out-of-network providers
Billing and network rules still apply; confirm member benefits and network status before scheduling