Medicare Advantage

Medical Policy

Policy Bulletin User Information

Policy Types and Descriptions

Policy Types and Descriptions: learn about Medicare Advantage medical and claim payment policies

The Company's Medicare Advantage benefit programs are composed of policy bulletins that address medical and claim payment-related topics:

Medical Policy

Medical policy bulletins are the Company’s communications to providers, members, and Company associates describing the Company’s coverage position on medical and behavioral health care services. This includes laboratory tests, diagnostic procedures, preventive interventions, and treatments (e.g., drugs/biologics, devices, and medical/surgical procedures).

The Company primarily relies on national coverage determinations (NCDs), local coverage determinations (LCDs), and other coverage guidance from the Centers for Medicare and Medicaid Services (CMS) and local Medicare contractors in the development of its Medicare Advantage medical policies. When Medicare coverage criteria are not fully established in applicable Medicare statutes, regulations, NCDs or LCDs, CMS allows Medicare Advantage plans to develop publicly accessible internal coverage criteria. The internal coverage criteria are based on current evidence in widely used treatment guidelines or clinical literature. Current, widely used treatment guidelines are those developed by organizations representing clinical medical specialties, and refers to guidelines for the treatment of specific diseases or conditions. Acceptable clinical literature includes large, randomized controlled trials or prospective cohort studies with clear results, published in a peer-reviewed journal, and specifically designed to answer the relevant clinical question, or large systematic reviews or meta-analyses summarizing the literature of the specific clinical question.

In accordance with federal regulations, coverage criteria are not fully established by CMS when:

(A) additional, unspecified criteria are needed to interpret or supplement general provisions in order to determine medical necessity consistently. The MA organization must demonstrate that the additional criteria provide clinical benefits that are highly likely to outweigh any clinical harms, including from delayed or decreased access to items or services;
(B) NCDs or LCDs include flexibility that explicitly allows for coverage in circumstances beyond the specific indications that are listed in an NCD or LCD; or
(C) There is an absence of any applicable Medicare statutes, regulations, NCDs or LCDs setting forth coverage criteria.

Medical policies may be developed or revised as a result of any of the following:

Creation of or changes to NCDs, LCDs, or other coverage guidance from Medicare
Emerging and/or new health care technologies
Changes in existing technologies
Federally mandated coverage requirements
Scheduled review of existing policies
Updates to medical codes (e.g., Current Procedural Terminology [CPT], Healthcare Common Procedure Coding System [HCPCS])

The process of medical policy development and subsequent policy revision is an established method for consistent development and maintenance of medical policies and procedures in accordance with current standards of care, federal and state mandates, and accreditation standards. These include, but are not limited to those of CMS and the National Committee for Quality Assurance (NCQA), a private, not-for-profit agency that maintains accreditation standards for health plans. Medical policies are reviewed and updated on an annual basis, as CMS or local Medicare contractors update NCDs, LCDs, or other coverage guidance, or more frequently as new evidence becomes available. The policies are reviewed and approved by the appropriate committee(s) prior to publication.

Claim Payment Policy

Claim payment policy bulletins are the Company’s administrative communications to providers, members, and Company associates describing the Company’s coverage and reimbursement position on a specific topic; the requirements for coverage and reimbursement; the instructions for reporting specific services, a class of services, and/or codes (e.g., diagnosis, procedure, procedure code modifier); and/or a description of the claims system logic applied to procedure code combinations.

A claim payment policy is developed or revised as a result of any of the following:

Basic product benefits, limitations, or exclusion information
Changes to provider, ancillary, or facility contracts
Updates to medical codes (e.g., Current Procedural Terminology [CPT], Healthcare Common Procedure Coding System [HCPCS]) and/or claims system conventions
Federally mandated coverage requirements
Scheduled review of existing policies

These policies are reviewed and approved by the appropriate Company committee(s) prior to publication.

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