Medicare coverage criteria in medical decision-making

Priority Health Medicare uses criteria established by the Centers for Medicaid and Medicare Services (CMS) 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)
  • National Coverage Provisions (NCPs)
  • Local Coverage Determination Manual (LCDs)
  • Medicare Managed Care Manual

Priority Health Medicare utilization management criteria complies with national and local coverage decisions, general Medicare coverage guidelines and written coverage decisions of local Medicare contractors.

For services requiring prior authorization, nurses 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, our medical policy and/or InterQual® Level of Care criteria will be used.

This criteria will also be used by the Pharmacy and Behavioral Health departments as appropriate.