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Compliance Program

Compliance Program

Standard 2 — Medical Necessity And Appropriate Services

The university's academic health centers and health systems shall submit claims for payment to government, private, or individual payers for those services or items that are medically necessary and appropriate.

  • When ordering or providing services or items, university physicians (or other health care professionals authorized by law to order items or services) shall only order those services and items that are consistent with generally accepted medical standards for diagnosis or treatment of disease and are determined by the profession to be medically necessary and appropriate.

  • In some cases, a health care professional may determine that services are medically necessary or appropriate, but the patient's health plan may not cover those services. In those cases, a patient should refer to his or her health plan administrator to receive information about the process for disallowed claims or uncovered benefits.

  • Patients may request services that are not covered benefits. Such services may be provided as long as the patient has been given advance notice and has agreed to pay for the services. In these cases, the patient may request the submission of a claim for the services to protect his or her appeal rights with respect to those services or to determine the extent of the coverage provided by the payer.

  • Professional coding and documentation will be consistent with the standards established in the university and campus programs and relevant policies.