In order to submit claims to a healthcare plan, credentialed providers are required to establish medical necessity. Here at DYWC, our providers are credentialed on several major plans to help increase your accessibility to quality care. In compliance with our contracts, we must meet this ongoing need for establishment of medical necessity.

Industry standards define “Medical Necessity or “Medically Necessary” as healthcare services rendered by a provider exercising prudent clinical judgment, which are:

A. Consistent with:
1. The evaluation, diagnosis, prevention, treatment or alleviation of symptoms of an illness,
disease or injury defined by the current Diagnostic and Statistical Manual of Mental Disorders
(DSM)

2. Generally accepted standards of medical practice, as defined by credible scientific evidence
published in peer-reviewed medical literature, which are generally recognized by the
appropriate medical community, Physician Specialty Society recommendations and other
relevant factors

B. Clinically appropriate and designed to meet the individualized needs of the client with regard to
type, frequency, extent, site and duration of services

C. Considered effective to improve symptoms associated with the client’s illness, disease, injury or
deficits in functioning

D. Provided at the least restrictive and most clinically appropriate service or level of care to safely,
effectively, and efficiently meet the needs of the client

E. Required for reasons other than the convenience of the client, family/support system, physician or
other healthcare provider

F. Not a substitute for non-treatment services addressing environmental factors

G. Not more costly than an alternative service or services, which are at least as likely to produce
equivalent diagnostic or therapeutic results for the client’s illness, disease or injury

If you have questions about your eligibility in qualifying these requirements, please call or email our office and we will have one of our providers answer these questions for you. It’s important to note that all healthcare plans require medical necessity to be established and guidelines followed with utilizing services, even when there are no session limits imposed on plans. Plans that offer unlimited coverage still require the provider to meet these standards and guidelines.

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