Provider Resources

UM clinical staff use the following information, criteria, and hierarchy to make medical necessity determinations:

1. Health Plan (Administrative – eligibility and plan benefits)
   1. Evidence of Coverage (EOC)
   2. The Plan Benefit Package (PBP)
2. UM Clinical System Software (Administrative – eligibility and plan benefits)
3. CMS
   1. National Coverage Determination (NCD)
   2. Local Coverage Determination (LCD)
   3. LCDs outside of applicable Plan Service Area
   4. Medicare Benefit Policy Manuals, Transmittals and Publication
4. AAH Medical Coverage Policies (AAH-MCP)
5. Evidence Based Criteria
   1. MCG Care guidelines
   2. Medicare Drug Compendia
6. Other 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
• Dental

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.

Medical Necessity

“Medically Necessary” or “Medical Necessity” means health care services or supplies that a physician, exercising prudent judgement, would provide and/or order for a patient. The services must be:

1. in accordance with generally accepted standards of medical practice;
2. clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and
3. not primarily for the convenience of the patient, physician, or other health care provider, and
4. not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury, or disease

Align Senior Care utilizes the following Medical Necessity criteria to guide utilization management decisions. This may include, but is not limited to, decisions involving inpatient reviews, prior authorizations, level of care, and retrospective reviews.

1. Centers for Medicare and Medicaid (CMS) Criteria
2. MCG Care Guidelines.

NHC Advantage Medical Necessity criteria does not supersede state or Federal law or regulation.