Medicare coverage criteria
PriorityMedicare
SM will utilize criteria established by CMS (Centers for Medicaid and Medicare Services) to determine if services are covered. The coverage criteria include the following CMS manuals:
- Benefit Policy Manual
- Claims Processing Manual
- Medicare Secondary Payer Manual
- Program Integrity Manual
- National Coverage Determination Manual (NCDs)
- Local Coverage Determination Manual (LCDs)
For services requiring prior authorization, the nurses will access the website for NCDs and LCDs to locate the appropriate and most current
criteria for the case. When NCDs and LCDs are silent regarding specific criteria for covered services, the Priority Health Medical Policy will be
used. This criteria will also be used by the Pharmacy and Behavioral Health Departments as appropriate.
