Medicare local coverage determinations (LCDs)
Priority Health Medicare Advantage plans must provide members with all services covered by Original Medicare Parts A and B. The exceptions, which remain payable by Original Medicare but are not paid for by Priority Health Medicare, are:
- Hospice care
- Inpatient hospital stays when enrollment ends
- Clinical trials
In providing Part A and Part B coverage, we must ensure that coverage is consistent with general coverage guidelines included under Original Medicare in its manuals and instructions unless superseded by a Center for Medicare & Medicaid Services (CMS) instruction or regulation concerning Medicare Advantage ("Part C") plans.
Medicare payment policy
Priority Health Medicare applies Medicare medical policy as found either under National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs).
If a service classified by Original Medicare as a benefit is described in an LCD under Medicare Part C rules, the LCD must have been written by a local Medicare Administrative Contractor (MAC) with "jurisdiction for claims in the geographic area in which services are covered under the Medicare Advantage (MA) plan."
We administer Priority Health Medicare benefits using LCDs with jurisdiction for claims for the geographic region assigned, as follows:
- Inpatient (Part A) services: Wisconsin Physician Services (WPS-Medicare)
- Outpatient (Part B) services: Wisconsin Physician Services (WPS-Medicare)
- Durable medical equipment (DME): National Government Services (NGS)
- Home health services: National Government Services (NGS)
LCDs for other MACs may apply to State of Michigan Original Medicare beneficiaries. However, under Medicare Part C rules, we will only consider use of another MACs LCD if:
(1) The MAC has exclusive jurisdiction over a Medicare item or service when the service is provided by only one provider (for example, certain pathology and lab tests, etc.), or
(2) There is no LCD for the item or service identified by one of the intermediaries above and another MAC has an LCD covering the item or service.
In the absence of either an NCD or LCD, CMS regulations allow for use of Priority Health medical policies.
Non-contracted provider reimbursement
LCDs and NCDs apply to providers not contracted with Priority Health. We apply LCDs following Medicare Part C rules as provided in the Medicare Managed Care Manual, Chapter 4. We reimburse:
- Non-contracted providers outside our service region based on the LCDs of the provider's geographic location
- Non-contracted providers within our service region based on the same LCDs applied to contracted Priority Health Medicare providers
Providers who dispute the use of a particular LCD can file an appeal. Go to information on Medicare payment disputes and appeals.
If you dispute our use of one of the intermediaries identified above by citing another intermediary's LCD, you should also submit other supporting information for us to consider in making a decision.