Specific care and treatment may vary depending on individual need and the benefits covered under your contract. Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify or deny care for persons with similar illnesses or conditions. Policy Limitation: Member's Contract Controls Coverage Determinations. Members and providers should refer to the Member contract to determine if exclusions, limitations and dollar caps apply to a particular procedure, drug, service, or supply. The Policies do not constitute authorization or guarantee of coverage of any particular procedure, drug, service, or supply. No Authorization or Guarantee of Coverage. Members should consult with their treating physician in connection with diagnosis and treatment decisions. Health Net does not provide or recommend treatment to Members. The Policies do not constitute medical advice. In some states, prior notice or website posting is required before an amendment is deemed effective. Health Net reserves the right to amend the Policies without notice to providers or Members. For information regarding the definitions of terms used in the Policies, contact your provider representative. For information regarding the effective dates of Policies, contact your provider representative. In some states, prior notice or posting on the website is required before a policy is deemed effective. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. The Policy is effective as of the date determined by Health Net. The date of posting is not the effective date of the Policy.
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Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. In all cases, final benefit determinations are based on the applicable contract language. In order to be eligible, all services must be medically necessary and otherwise defined in the Member's benefits contract as described in this "Important Notice" disclaimer. The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment and services. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net's National Medical Advisory Council (MAC). The Member's contract defines which procedure, drug, service, or supply is covered, excluded, limited, or subject to dollar caps. The conclusion that a procedure, drug, service, or supply is medically necessary does not constitute coverage. Health Net may use the Policies to determine whether, under the facts and circumstances of a particular case, the proposed procedure, drug, service, or supply is medically necessary. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the Member's contract, including medical necessity requirements.
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The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service, or supply is medically necessary.
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