MNR List and Its Relationship to the Precertification or Prior Authorization list

Some health benefit plans do not require prior authorization or precertification for outpatient services. For those plans, outpatient services may be reviewed for medical necessity and coverage after the service is rendered. Outpatient services subject to post-service medical necessity or clinical coverage review are identified on the MNR list. The MNR list includes services which may be determined not to be covered, such as new or unproven technologies, cosmetic procedures and services impacted by specific plan exclusions or particular terms of coverage.

For codes on the MNR list, a customer or an HCP may request a pre-service coverage evaluation to determine if the service is likely to be covered or not. This is called a pre-determination, rather than a prior authorization or precertification. Pre-determination coverage evaluations are not required and do not result in an actual coverage decision. Therefore, appeal rights are not offered. The actual coverage decision is made after the claim is submitted post-service. If coverage is denied post-service, appeal rights are provided.

Definitions of medical necessity are not all the same. Check the applicable benefit plan for the exact definition. Below is an example of a typical medical necessity definition.

Sample Medical Necessity Definition

Medically Necessary Covered Services and Supplies are those determined by the Medical Director to be:

• required to diagnose or treat an illness, injury, disease or its symptoms;
• in accordance with generally accepted standards of medical practice;
• clinically appropriate in terms of type, frequency, extent, site and duration;
• not primarily for the convenience of the patient, Physician or other health care provider; and
• rendered in the least intensive setting that is appropriate for the delivery of the services and supplies. Where applicable, the Medical Director may compare the cost-effectiveness of alternative services, settings or supplies when determining least intensive setting.

Medical Necessity Review List

• Medical Necessity Review (MNR) List

California

The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.