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  2. Medical necessity - Wikipedia

    en.wikipedia.org/wiki/Medical_necessity

    The use of cannabis (also known as marijuana) for medical purposes is a notable medical necessity case. Cannabis is a plant whose active ingredients are widely reported by patients to be effective in pain control for various conditions, usually neuropathic in nature, in which common painkillers have not had great benefit.

  3. Utilization management - Wikipedia

    en.wikipedia.org/wiki/Utilization_management

    UM is the evaluation of the appropriateness and medical necessity of health care services, procedures, and facilities according to evidence-based criteria or guidelines, and under the provisions of an applicable health insurance plan. Typically, UM addresses new clinical activities or inpatient admissions based on the analysis of a case.

  4. Certificate of medical necessity - Wikipedia

    en.wikipedia.org/wiki/Certificate_of_medical...

    Physician's News Digest article on Certificates of Medical Necessity; Statutory definition of a CMN at the SSA website; Medicare manual that provides exhaustive information about the practical use of CMNs, particularly section 5.3. This is the official source of information for contractors administering the Medicare system about the use of CMNs.

  5. Is Wegovy covered by Medicare? - AOL

    www.aol.com/wegovy-covered-medicare-132102666.html

    Some people may be eligible for Medicare coverage for Wegovy if they meet medical criteria for heart disease risk. ... medical conditions that make it a medical necessity. ... medical uses become ...

  6. Prior authorization - Wikipedia

    en.wikipedia.org/wiki/Prior_authorization

    Prior authorization is a check run by some insurance companies or third-party payers in the United States before they will agree to cover certain prescribed medications or medical procedures. [2] There are a number of reasons that insurance providers require prior authorization, including age, medical necessity, the availability of a generic ...

  7. Medical billing - Wikipedia

    en.wikipedia.org/wiki/Medical_billing

    A medical biller then takes the coded information, combined with the patient's insurance details, and forms a claim that is submitted to the payors. [2] Payors evaluate claims by verifying the patient's insurance details, medical necessity of the recommended medical management plan, and adherence to insurance policy guidelines. [4]

  8. Certificate of need - Wikipedia

    en.wikipedia.org/wiki/Certificate_of_need

    [1] [2] [3] Certificates of need are necessary for the construction of medical facilities in 35 states and are issued by state health care agencies: The certificate-of-need requirement was originally based on state law. New York passed the first certificate-of-need law in 1964, the Metcalf–McCloskey Act.

  9. Managed care - Wikipedia

    en.wikipedia.org/wiki/Managed_care

    Utilization management (UM) or utilization review is the use of managed care techniques such as prior authorization that allow payers to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines. UM criteria are medical guidelines which may be developed in house ...