Coverage and Utilization Management Decisions
We base coverage decisions, including medical necessity decisions, on:
- Member’s benefits
- State and federal requirements
- The contract between us and the plan sponsor
- Medicare guidelines including National Coverage Determination (NCD) and Local Coverage Determination (LCD) guidelines
- Medicare Benefit Policy Guide (MA members)
- Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines, and Coverage Summaries
Our employees, contractors, and delegates do not receive financial incentives for issuing non-coverage decisions or denials. We and our delegates do not offer incentives for underutilization of care/services or for barriers to care/service. We do not hire, promote or terminate employees or contractors based on whether they deny benefits.
We use tools such as UnitedHealthcare medical policies, and third party resources (such as MCG Care Guidelines and other guidelines), to assist us in administering health benefits and determining coverage. We also use tools and third party resources to assist clinicians in making informed decisions.
These tools and resources are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and are not equivalent to the practice of medicine or medical advice.
Clinical Coverage Summaries and Policy Guidelines for Medicare Advantage
We follow CMS guidance (including NCD and LCD guidelines) if the tools and resources we use contradict CMS guidance. If we do not perform a pre-service clinical coverage review, we may use Medicare guidelines, including NCD and LCD guideline to perform a clinical review when we receive the claim.
Some plans require prior authorization through a preservice clinical coverage review. Once you notify us of any planned service, item or drug on our Advance Notification/Prior Authorization List, we will inform you of any required information necessary to complete the clinical coverage review as part of our prior authorization process. We will notify you of the coverage decision within the timeframe required by law.
You and our member must be aware of coverage decisions before you render services. If you provide the service before a coverage decision is made, and we determine the service is not covered, we may deny the claim. The member cannot be billed. If you provide services prior to our decision, the member cannot make an informed decision about whether to pay for and receive the noncovered service.
Clinical Coverage Review
You can review the Medical Records Requirements for Pre-Service Requests which lists required information by service. If you submit required information with the advance notification/prior authorization, your review will go faster. You must:
- Return calls from our care management team and/or Medical Director.
- Submit the most correct and specific code available for the services.
- Comply with our request for additional information or documents and discussions, including any requests for medical records and imaging studies/reports:
- If you receive our request before 1 p.m. local time:
- Supply the information within four hours
- If you receive our request after 1 p.m. local time:
- Provide the information no later than 12 p.m. local time the next business day
Medical & Drug Policies and Coverage Determination Guidelines for Commercial Members
We develop Medical Policies, Medical Benefit Drug Policies, and Coverage Determination Guidelines to support the administration of medical benefits. They are only for informational purposes; they are not medical advice. You are responsible for deciding what care to give our members. Members should talk to their care providers before making medical decisions.
Benefit coverage is determined by:
- Laws that may require coverage
- The member’s benefit plan document
- Summary Plan Description
- Schedule of Benefits
- Certificate of Coverage
The member’s benefit plan document identifies which services are covered, which are excluded, and which are subject to limitations. If there is a conflict, the member’s benefit plan document supersedes our policies and guidelines.
We develop our policies and guidelines as needed. We regularly review and update them. They are subject to change. We believe the information in these policies and guidelines is accurate and current as of the publication date. We also use tools developed by third parties, such as the MCG Care Guidelines, to help us manage health benefits.
Medical Policy Updates
For more information on Medical Policy updates, refer to the Medical Policy Update Bulletin section of Chapter 17: Provider Communications.