Medical Necessity

"Medical Necessity" is used to refer to the accepted medical acts performed on the Insured, and which are justified as reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care and consistent with the exact disease, illness, injury or condition of the Insured. Meeting medical necessity requirements is essential for the successful financial reimbursement from payers.

ADAA’s rules engine system, uses medical rules and coding edits to review procedure and diagnosis codes in place; it detects the performed procedure compatibility with the patient’s diagnosis as mentioned in the medical report, ensuring that all performed procedures relating to a certain diagnosis code are considered medically necessary.