Covered Service Requirements

In order to be covered, a health service must be determined by prevailing community standards or customary practice and usage to be all of the following:

1. Medically necessary
2. Appropriate and effective for the medical needs of the patient
3. The most cost effective health service available for the medical needs of the patient
4. Able to meet quality and timeliness standards
5. Able to represent an effective and appropriate use of program funds
6. Able to meet specific limits outlined in rules adopted by DHS and explained in this manual
7. Personally furnished by a provider, except as specifically authorized in this manual

For information regarding out-of-country care, refer to Service Authorization.

PW_03-19_154
Updated_03/15/2019