Beacon does not provide rewards or incentives, either financially or otherwise, to any of the individuals involved in conducting utilization review, for issuing denials of coverage or service, or inappropriately restricting care.
Utilization-related decisions are based on the clinical needs of the members, benefit availability, and appropriateness of care. Objective, scientific based criteria and treatment guidelines, in the context of provider or member-supplied clinical information, guide the decision-making process.
Medical Necessity Criteria
Beacon’s clinical criteria, also known as medical necessity criteria, are based on nationally recognized resources.
Medical necessity criteria may vary according to individual state and/or contractual requirements and member benefit coverage.
These criteria are available for review in our provider handbook.