Determining Medical Necessity
MFAW Guidebook
Determining Medical Necessity
The MFAW SC authorizes services based on medical necessity. There are several factors used to ensure the criteria for medical necessity are met, including, but not limited to:
- Services are clinically appropriate, in terms of type, frequency, extent, site, duration and are considered effective for the participant’s illness, injury or disease;
- Services are authorized at an appropriate level of service that supports the safety, health, and well being of the participant but does not replace the parents and/or responsible party(ies) as the main caregiver(s);
- Services are authorized on a case-by-case basis based on credible evidence using the applicable assessment tools that apply to the actual direct care and treatment of the participant;
- Services are delivered/performed in accordance to the identified medical treatment needs but do not include interventions in which prompting, cueing, and/or redirection of either a verbal or physical nature is necessary to ensure the safety, health, and well-being of the participant; and
- Services are not for the convenience of the participant or his/her parents and/or responsible party(ies).
The SC will determine medical necessity and eligibility for MFAW services by using the Client Assessment and Level of Care Determination forms. In addition to these tools, the SC may also review other sources of information to obtain sufficient understanding of the participant’s care, specific medical needs, and interventions, which may include:
- Physician's orders, plans of care, and/or medical reports,
- Provider progress notes and reports,
- A previous SHCN record,
- Documentation of verbal reports from the hospital discharge planners, service provider(s), Department of Mental Health (DMH) Case Managers, and/or Family Support Division Case Workers, and
- Parent(s) and/or responsible party(ies) strengths and challenges that may affect the ability to provide care.