November 2009

Procedures and services deemed investigational or not medically necessary

In September, we mailed amendments/addendums to our provider agreements. The changes, effective January 1, 2010, are summarized below:

• Medical Necessity and Medically Necessary:  Effective January 1, 2010, WAC 284-53-010 requires carriers to utilize a definition for Medical Necessity and Medically Necessary that is specific to chemical dependency services. The definition for Medical Necessity and Medically Necessary has been updated to be compliant with WAC 284-53-010.
• Prior to rendering services deemed investigational to members enrolled in Medicaid and Healthy Options Basic Health, the provider must obtain the member's written consent in order to charge the member. For all other members, written consent is not required for services deemed investigational. However, Asuris encourages the provider to notify the member before services are rendered that they may be deemed non-covered and, if non-covered, will be the member's financial responsibility.

 

Note: The Asuris Clinical Edits by Code lists contain investigational codes and supporting documentation requirements.

Return to newsletter index »