The treating physician or primary care provider must submit to ConnectiCare clinical evidence showing that the patient meets the criteria for the medical treatment, surgical procedure, or pharmaceutical/biologic agent. Without this documentation and information, ConnectiCare will not be able to properly review the request for prior authorization.
The clinical review criteria posted on this site reflect how ConnectiCare determines whether certain services or supplies are medically necessary. ConnectiCare established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology or pharmaceutical/biological, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). ConnectiCare expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information.
Each benefit plan defines which services are covered. The conclusion that a particular service, supply, or pharmaceutical/biologic agent is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by ConnectiCare since some plans exclude coverage for services or supplies that ConnectiCare considers medically necessary. If there is a discrepancy between this policy and a member's benefit plan, the benefit plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state or the federal government.
ConnectiCare clinical review criteria are developed to assist in administering plan benefits and do not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members.