On March 30, 2010, the Health Care and Education Reconciliation Act of 2010 (P.L.111-152) was signed into law. The two laws are collectively referred to as the Affordable Care Act. The Affordable Care Act established new competitive private health insurance markets called Marketplaces, or Exchanges. By providing a place for one-stop shopping, Marketplaces make purchasing health insurance easier and more transparent, and put greater control and more choice in the hands of individuals and small businesses.
Sections 1311(e)(3)(A)-(C) of the Affordable Care Act as implemented at 45 CFR 155.1040(a)-(c) and 156.220, establish new standards for qualified health plan (QHP) issuers to submit specific information related to transparency in coverage. QHPs are required to post and make data related to transparency in coverage available to the public.
Community Health Choice is providing all required data elements below. Please click on the links to obtain additional information about each data element.
Medical Necessity Definition: Medical Necessity is the review of requested covered health-care services or supplies needed to prevent, diagnose or treat a covered illness, injury, condition, disease or its symptoms in accordance with plan benefits.
Failure to obtain prior authorization may result in rejection or denial of benefits