Medical Necessity

Definitions of Medical Necessity and Investigational Services

Health Net's has provided clarification of terms used in its medical policies for medical necessity, investigational or experimental, and not medically necessary and not investigational. This clarification should enable participating physician groups (PPGs) to more quickly determine whether a service is considered investigational and, therefore, submit the request for a proposed service timely to Health Net for utilization management (UM) review and determination based on the terms of the provider's contract.