Knowledge Center

​​​​​​​ Disclaimer

These criteria must be used and interpreted within the framework of the CHI Essential Benefit Package, the Insurance Drug Formulary, and other policies and circulars issued by the Council of Health Insurance.

​​​​​​ Medical Necessity

Medical Necessity criteria are sets of criteria used to determine whether a particular health service or treatment is medically necessary and appropriate for the beneficiary based on current scientific recommendations. These criteria are used by health care providers and insurance companies to ensure that appropriate health care services are provided and covered appropriately to improve the quality of health care. These criteria focus on:

​​​​​​ Medical Necessity

The treatment or intervention must be necessary to treat or diagnose a medical condition or to prevent development of disease or worsening of an existing condition.

​​​​​​ Clinical Appropriateness

The treatment or intervention must be appropriate to the beneficiary’s health condition based on established clinical guidelines and standards. This requires that the treatment or intervention to be compatible with the beneficiary’s specific condition and achieve the desired outcome.

​​​​​​ Evidence-Based

There must be sufficient evidence to support the effectiveness of the treatment or intervention based on reliable medical evidence.

​​​​​​Cost-Effectiveness

Treatment or intervention should be cost-effective compared to other available options. This ensures that the treatment or intervention provides adequate value for the associated expenses.

​​​​​​ Patient-Specific

Treatment should be tailored to the individual needs of beneficiaries, considering the beneficiaries' medical history and specific health conditions.

​​​​​​ Preventive Care

Medical necessity may also include certain preventive services that are considered necessary to prevent diseases or detect health conditions at early stage.

​​​​​​ Documentation

Documentation must be provided to justify the medical need for the treatment or procedure. This can include clinical notes, test results, and treatment plans.

​​​​​​ Transparency

These criteria achieve transparency between health care providers and insurance companies.

​​​​​​ Protecting beneficiaries

Preventing harm that may occur to CHI beneficiaries due to medically unjustified intervention or treatment or due to unjustified denial of service coverage.

These criteria help ensure that beneficiaries receive appropriate health care and that health costs are managed effectively by providers and insurance companies.