Health insurance companies cover services they define as medically necessary. Medical necessity is a decision made by a health plan as to whether the treatment, test, or procedure is

Discussion Topic- Concepts of Managed Care 

Health insurance companies cover services they define as medically necessary. Medical necessity is a decision made by a health plan as to whether the treatment, test, or procedure is necessary for a patient’s health or to treat a medical problem. Third-party payers (aka Insurance companies or health plans) often require documentation to illustrate medical necessity for treatment before payment will be made.

For your main Discussion post, evaluate and examine medical necessity from a provider’s (doctor, hospital, clinic, etc.) point of a view and from a payer’s/health plan’s (Aetna, Cigna, Affinity, Healthfirst, etc.) point of view.

Research then discuss the role evidence-based clinical criteria and guidelines play with regard to medical necessity.

 At least 250 words 

Chapter 5

Required Textbooks:Kongstvedt, P., Health Insurance and Managed Care: What They Are and How TheyWork, 5th. Edition. Sudbury, MA: Jones and Bartlett.ISBN- 978-1-284-15209-8 or EBook-ISBN-978-1-284-09487-9