Members Resources

Clinical Determination Criteria

Prior Authorization NHC Advantage

NHC Advantage Internal Coverage Criteria

Medicare Part A Skill in Place/Skilled Nursing Facility

As a company, NHC 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. National Coverage Determinations (NCD) a) Local Coverage Determinations (LCD) b) Local Coverage Articles (LCA), when used on conjunction with LCD.
2. 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).
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 the above listed Clinical Determination Criteria 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)

Medicare Internet-Only Manuals (IOMs)

Other Approved Evidence Based Resources and Medical Literature include:

• MCG

Care Guidelines are the protected intellectual property of MCG. NHC Advantage is not able to distribute them without the permission of MCG. MCG has provided a tool that allows our members and prospective members to view relevant MCG guidelines, however you will not be able to print them.

Follow the instructions below to access the MCG Guidelines:

Step 1: Access guidelines here, read the disclaimer, and accept the terms and conditions.

Step 2: Complete the User information form.

Step 3: Complete the verification process to continue.

Step 4: Click on the arrow icon.

Step 5: Click on the guidelines you wish to view.

• Additional Approved Evidence Based Criteria Resources can be found 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 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).