Tuesday, August 23, 2016

Definition - What is Emergency, Medical necessity

DEFINITIONS

Emergency - A serious medical condition or symptom resulting from Injury, Sickness or [1Mental Illness][2mental illness] which is both of the following:

• Arises suddenly

• In the judgment of a reasonable person, requires immediate care and treatment, generally received within 24 hours of onset, to avoid jeopardy to life or health

Medically Necessary (UHIC 2011 COC) - health care services provided for the purpose of preventing, evaluating, diagnosing or treating a Sickness, Injury, [Mental Illness,] [mental illness,] substance use disorder, condition, disease or its symptoms, that are all of the following as determined by us or our designee, within our sole discretion.

• In accordance with Generally Accepted Standards of Medical Practice

• Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your Sickness, Injury, [Mental Illness,] [mental illness,] substance use disorder, disease or its symptoms

• Not mainly for your convenience or that of your doctor or other health care providerNot more costly than an alternative drug, service(s) or supply that is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your Sickness, Injury, disease or symptoms


Generally Accepted Standards of Medical Practice are standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, relying primarily on controlled clinical trials, or, if not available, observational studies from more than one institution that suggest a causal relationship between the service or treatment and health outcomes.

If no credible scientific evidence is available, then standards that are based on Physician specialty society recommendations or professional standards of care may be considered. We reserve the right to consult expert opinion in determining whether health care services are Medically Necessary. The decision to apply Physician specialty society recommendations, the choice of expert and the determination of when to use any such expert opinion, shall be within our sole discretion.


We develop and maintain clinical policies that describe the Generally Accepted Standards of Medical Practice scientific evidence, prevailing medical standards and clinical guidelines supporting our determinations regarding specific services. These clinical policies (as developed by us and revised from time to time), are available to Covered Persons on [myuhc.com] or by calling Customer Care at the telephone number on your ID card, and to Physicians and other health care professionals on UnitedHealthcareOnline.

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