Master Payment Policy — medical necessity and payment determinations
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Governance of UHA's approach to medical necessity determinations, payment criteria, and use of external authoritative sources to guide coverage and prior authorization decisions for University Health Alliance members and providers.
No material clinical or coverage changes in this revision.
Master Coverage and Medical Necessity Approach
Master approach to coverage criteria
Covered when ALL of the following guide UHA determinations:
ALL of the following
- UHA bases medical necessity and payment decisions on the Hawaii Revised Statutes definition of medical necessity and balances appropriateness, efficacy, and cost‑effectiveness.
- UHA seeks and prefers current, scholarly, authoritative, and validated sources — including standard recommendations and criteria published by professional societies (e.g., ASCO, NCCN, ACIP, ACP, ASBS, MCG, InterQual, USPSTF, ACOG).
- UHA uses peer‑reviewed journals (for example, JACC, ACR) and guidance published by CMS as primary external references for coverage criteria.
- UHA references routinely updated and annotated payment criteria from prevailing payers nationwide, and may consider opinions from Hawaii‑based experts, independent review organizations, and specialty society briefs.
- When requested, UHA will provide the source(s) used to support a particular determination; providers may submit additional information for consideration.
ALL of the following
- For clinical scenarios not addressed by external authoritative sources, UHA maintains internal payment policies (such as Emerging Technology, Medical Necessity Determination, Never Events/Hospital Acquired Conditions/Serious Medical Errors) and the Medical Benefits Guide, which will be applied as appropriate and provided with determinations.
- This payment policy is a guide to coverage and administrative directives; it is not practice‑of‑medicine instruction, does not guarantee payment, and specific provider contract terms or individual member benefit plans may supersede the policy.
Referenced Guideline Sources and Coding Notes
Prior Authorization, Administrative Directives, and Reconsideration
Prior authorization and administrative directives may apply
This payment policy is a guide to coverage; the need for prior authorization and other administrative directives may still apply. It is not a guarantee of payment, and specific provider contract terms or members' individual benefit plans may affect coverage determinations.
- UHA may require prior authorization or other administrative directives despite guidance in this policy.
- Coverage indicated in this policy does not guarantee payment; provider contracts and member benefit plans may override.
Reconsideration and peer-to-peer communication allowed
Providers may request that UHA reconsider medical necessity determinations and may engage in direct peer-to-peer communication to discuss supporting documentation.
- Submit supporting documentation when requesting reconsideration of medical necessity.
- Direct peer communication with UHA is permitted to discuss determinations.
Key Definitions and Scope
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