About this webinar
Role of the Medical Director
- All plans must employ a medical director who is responsible for ensuring the clinical accuracy of all coverage decisions involving medical necessity.
- CMS does not; however, expect that the medical director review every medical necessity decision.
- The plan must establish a process for when a medical director must be involved.
QUESTION FROM THE AUDIENCE
- Does a Medical Director or Physician needs to see all denied coverage determinations with lack of medical necessity?
- Can it be a Pharmacist?
ANSWER TO QUESTION
Who Must Review an Initial Determination
If a plan initially reviews a request and expects to issue a partially or fully adverse decision based on medical necessity, the review must be completed by a physician, as defined in section 1861(r) of the Act, or other appropriate healthcare professional who has:
- Sufficient medical and other expertise;
- Knowledge of the Medicare coverage criteria; and
- A current and unrestricted license to practice within the scope of his or her profession in a State, Territory, Commonwealth of the United States (that is, Puerto Rico), or the District of Columbia.
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