We issue a denial letter if the level of care or any inpatient bed days are not medically necessary. We decide this through concurrent or retrospective review. We use nationally recognized criteria and guidelines to determine if the service/care was medically necessary under the member’s benefit plan. For MA members, we use Medicare coverage guidelines. These guidelines overrule the nationally recognized criteria. We can provide the criteria to you upon request.
A facility denial letter is available to the member upon request.