Clinical Determination Criteria

Prior Authorization KeyCare Advantage

KeyCare Advantage Internal Coverage Criteria

Medicare Part A Skill In Place/Skilled Nursing Facility

As a company, KeyCare Advantage has made the decision to strictly follow Medicare Benefit Manual, Chapter 8 for all Skilled in Place/Skilled Nursing Facility Authorization Request decisioning.

Medicare Part B Outpatient

Medicare Advantage medical policies identify the clinical criteria for determining when medical services are considered ‘reasonable and necessary’ (medically necessary). Medicare Advantage plans are required by CMS to provide the same medical benefits to Medicare Advantage members as original Medicare. As such, whenever possible, Medicare Advantage medical necessity decisions are based on Medicare coverage manuals, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) used in conjunction with an LCD, when available. 

If there is no applicable NCD, LCD, or LCA (used in concert with an LCD), for the service under review, then other evidence-based criteria may be applied. In addition, each member’s unique clinical situation is considered in conjunction with current CMS guidelines.

The following hierarchy is used to determine Medicare Advantage Medical Policy:

  1. CMS Coverage Manuals or other CMS-Based Resource: Coverage provisions in interpretive manuals are instructions that are used to further define when and under what circumstances items or services may be covered (or not covered)
  2. National Coverage Determinations (NCD) a) Local Coverage Determinations (LCD) b) Local Coverage Articles (LCA), when used on conjunction with LCD
  3. In circumstances when Medicare guidelines are not available the Plan will utilize clinical criteria from outsource vendors MCG (formerly Milliman Care Guidelines) and approved Evidence Based Resources and Medical Literature.

 

 

Please see below on ways to access that information.

National Coverage NCD Report Results (cms.gov)

Local Coverage Final LCDs by Contractor Report Results (cms.gov)

Local Coverage Articles by Contractor Report Results (cms.gov)

 

In order to access the MCG guidelines used by AAH you will need to request a one-time username and passcode by calling one of the following numbers:

Provider Services: 1-844-206-1205 (TTY 711)
Member Services: 1-844-206-1205 (TTY 711)

Once you obtain that information, please enter it into the pertinent forms on the web page linked HERE

 

Definitions:

Internet Only Manual (IOM): The Internet-only Manuals (IOMs) are a replica of the Agency’s official record copy. They are CMS’ program issuances, day-to-day operating instructions, policies, and procedures that are based on statutes, regulations, guidelines, models, and directives. The CMS program components, providers, contractors, Medicare Advantage organizations and state survey agencies use the IOMs to administer CMS programs. They are also a good source of Medicare and Medicaid information for the general public.

National Coverage Determination (NCD): a decision by Medicare and their administrative contractors that provide coverage information and determine whether services are reasonable and necessary. These guidelines apply across the United States wherever Medicare provides health coverage.

Local Coverage Determination (LCD)- a decision by Medicare and their administrative contractors that provide coverage information and determine whether services are reasonable and necessary. These guidelines apply only to the areas of the country which the local Medicare Administrative Contractor, who author/adopts the LCD, has jurisdiction over.

Local Coverage Articles (LCA): Local Coverage Articles are a type of educational document published by the Medicare Administrative Contractors (MACs). Articles often contain coding or other guidelines that are related to a Local Coverage Determination (LCD).