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:

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.