Ohio Admin. Code 5160-1-01 - Medicaid medical necessity: definitions and principles
Medical necessity is a fundamental
concept underlying the medicaid program.
(A) Medical necessity for individuals covered
by early and periodic screening, diagnosis and treatment (EPSDT) is
defined as
criteria
of coverage for procedures, items, or services that prevent, diagnose,
evaluate, correct, ameliorate, or treat an adverse health condition such as an
illness, injury, disease or its symptoms, emotional or behavioral dysfunction,
intellectual deficit, cognitive impairment, or developmental
disability.
(B) Medical necessity
for individuals not covered by EPSDT is defined
as
criteria of coverage for procedures,
items, or services that prevent, diagnose, evaluate, or treat an adverse health
condition such as an illness, injury, disease or its symptoms, emotional or
behavioral dysfunction, intellectual deficit, cognitive impairment, or
developmental disability and without which the person can be expected to suffer
prolonged, increased or new morbidity; impairment of function; dysfunction of a
body organ or part; or significant pain and discomfort.
(C) Conditions of medical necessity
for a procedure, item, or service are met if all
the following apply:
(1)
It
Meets
meets generally accepted standards of medical
practice;
(2)
It is
Clinically
clinically
appropriate in its type, frequency, extent, duration, and delivery
setting;
(3)
It is
Appropriate
appropriate to the adverse health condition for which
it is provided and is expected to produce the desired outcome;
(4)
It
Is
is the
lowest cost alternative that effectively addresses and treats the medical
problem;
(5)
It
Provides
provides
unique, essential, and appropriate information if it is used for diagnostic
purposes; and
(6)
It is
Not
not provided primarily for the economic benefit of the
provider nor for the sole convenience of the
provider or anyone else other than the recipient.
(D) The fact that a physician, dentist or
other licensed practitioner renders, prescribes, orders, certifies, recommends,
approves, or submits a claim for a procedure, item, or service does not, in and
of itself make the procedure, item, or service medically necessary and does not
guarantee payment for it.
(E) The definition and conditions of medical
necessity articulated in this rule apply throughout the entire medicaid
program. More specific criteria regarding the conditions of medical necessity
for particular categories of service may be set forth within
the Ohio department of medicaid ( ODM) coverage policies or rules.
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/07/1977, 09/19/1977, 12/21/1977, 12/30/1977, 07/01/1980, 02/19/1982, 10/01/1984, 10/01/1987, 06/01/1991, 05/30/2002, 07/01/2006, 03/22/2015
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