Physicians, not payers, determine medical necessity. We therefore suggest use the term coverage criteria. See proposed wording.

Existing Wording:

Payer A Seeks Insured Person/Patient B’s Active Conditions from Provider C to confirm medical necessity.

Proposed Wording:

Payer A Seeks Insured Person/Patient B’s Active Conditions from Provider C to confirm Payer A’s coverage criteria have been met for a service.

(Comment 7 - imported by: Jean Duteau)