1.  We receive a provider’s request for a service or item.
2. We ask the provider to give us a letter that tells us all the details about the service or item and that also explains why the member needs the service or item.
3.  We perform a web-based literature search to find out more details about the service or item. These details could include:

• • • Whether the service or item was approved by the Food and Drug Administration
    • If other providers have used the service or item and wrote about how it worked for them
    • Whether the service or item is accepted as useful by other providers. If a literature search does not yield relevant information about the service or item, we contact medical experts directly to get details about the service or item.

4. After the details of the service or item are provided to us from either the literature search or the medical expert, one of our Medical Directors reviews the details about the service or item. After review, the Medical Director makes a decision about whether the service or item should be covered.

These steps help ensure that the service or item is both safe and helpful for you.  Experimental services or procedures are not covered under Jefferson Health Plans benefit package.