House Bill 228 Medical Necessity Revised

July 18, 2007

Pertaining to the definition of Medical Necessity

Effective July 13th, the definition of "medical necessity" under managed care law is now standardized under all HMO's. Prior to this legislation carriers were required to file the definition of "medical necessity" with the state. 33:1 New Paragraph; Definition Added: Medical Necessity: Amend RSA 420-J:3 by inserting a paragraph after paragraph XXV-a the following new paragraph:

Under Section XXV-b. "Medical necessity" means health care services or products provided to an enrollee for the purpose of preventing, stabilizing, diagnosing, or treating an illness, injury, or disease or the symptoms of an illness, injury, or disease in a manner that is:

(a) Consistent with generally accepted standards of medical practice;
(b) Clinically appropriate in terms of type, frequency, extent, site, and duration;
(c) Demonstrated through scientific evidence to be effective in improving health outcomes;
(d) Representative of “best practices” in the medical profession; and
(e) Not primarily for the convenience of the enrollee or physician or other health care provider.

33:2 Repeal. RSA 420-J:7-a, relative to filing requirements for medically necessary definitions, is repealed.
33:3 Effective Date. This act shall take effect 60 days after its passage.
Approved: May 14, 2007

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