Definition: A prerequisite, often intended as a rate-limiting or cost-containment step, in the provision of care and treatment to an insured patient. A practitioner who expects to be paid for a service must use paperwork and telephone contact with a designated entity (often clerks, but sometime medical professionals), often a TPA, to determine whether the proposed treatment or procedure is deemed medically necessary for the health and welfare of the covered party.
See Also: benefit, health maintenance organization, managed care, fee-for-service insurance, traditional indemnity insurance
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Examples: glitazone, GI cocktail, etc.
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