Medical Policies
Our Medical Policies (the "Policies") assist us in administering plan benefits and determining whether a particular procedure, drug, service or supply is medically necessary. They are not intended to give medical advice or tell physicians and other providers how to practice.
All services must be medically needed unless the member's benefit plan coverage document states otherwise. That document defines member benefits in addition to eligibility requirements, and coverage exclusions and limits.
- For Medi-Cal plans, appropriate coverage guidelines take precedence over the Plan's Policies and must be applied first.
- If legal or regulatory mandates apply, they may override the Plan's Policies.
- If there are any conflicts between the Plan's Policy guidelines and related member benefits contract language, the benefits contract will apply.
Physicians and other providers can view Policies for: