Medical Necessity in Private Health Plans: Implications for Behavioral Health Care

3 CE Hours
131 members have taken this course

This course has been retired. We regularly update our course catalog to ensure relevance.

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About the Course

This report addresses how the term “medical necessity” is defined in private health insurance coverage decisions. It summarizes a review of the literature, an extensive review of legal cases that challenge insurer decisions, materials prepared by the insurance industry, consultation with experts in the field, a review of investigations conducted by state departments of insurance and attorneys general, and interviews with health care executives regarding the decision making process itself. The report does not explore factors that can affect access to care that might be considered clinically necessary by treating professionals or the effects of medical necessity decisions on therapeutic outcomes.

This course is based on the reading online article, Medical Necessity in Private Health Plans: Implications for Behavioral Health Care created by Rosenbaum, S., et al.

Publication Details

Journal/Publisher: U.S. Department Of Health And Human Services
Publication Date: 2003

Course Material Author

Rosenbaum, S., et al.
Center for Mental Health Services, Substance Abuse, and Mental Health Services Administration staff.

Rosenbaum, S., et al. authored the material only, and was not involved in creating this CE course. They are identified here for your own evaluation of the relevancy of the material this course is based on.

Course Creator

Keith Gibson, Ph.D.

Target Audience

This course is recommended for health care professionals, especially psychologists, counselors, social workers, and nurses who seek knowledge about the role private health plans play in determining medical necessity of behavioral health care. It is appropriate for all levels of participants' knowledge.

Learning Objectives

After taking this course, you should be able to:

  1. 1 Become familiar with and be able to critique peer-reviewed and professional literature on medical necessity.
  2. 2 Describe industry practices and judicial opinions that have examined decision-making procedures.
  3. 3 Describe state insurance laws and the procedural elements of their independent review statutes.
  4. 4 Identify relevant federal laws pertaining to medical necessity reviews.

Disclosure to Learners

CE Learning Systems adheres to the ACCME's Standards for Integrity and Independence in Accredited Continuing Medical Education. Any individuals in a position to control the content of a CE activity – including faculty, planners, reviewers, or others ― are required to disclose all relevant financial relationships with ineligible entities (formerly known as commercial interests).

The following relevant financial relationships have been disclosed by this activity's planners, faculty, and the reviewer:

Planners and Reviewers

The planners of this activity have reported that they have no relevant financial relationships.

Material Authors

Any relevant financial disclosures for course material authors can be found in the article.

Course Creator

Keith Gibson, Ph.D. – There are no known relevant financial relationships to disclose.

Commercial support

There is no commercial support for this distance-learning course.

$27

Course Details

3 CE Hours
Reading Online
Course 101115

Availability

This course is retired. It is no longer available.

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