We also publish our payment policies to help providers understand the way a submitted claim will be processed and paid. To access these policies, log in and go to Office Resources>Policies & Guidelines>Payment Policies.
We also publish our payment policies to help providers understand the way a submitted claim will be processed and paid.
Medicare Advantage coverage determinations are made using Medicare coverage guidelines: CMS National Coverage Determination (NCD) policies and Local Coverage Determination (LCD) policies. When there is no NCD or LCD, we follow our commercial medical policies for Medicare Advantage members. Refer to medical policy 132, Medicare Advantage Management, for a directory of commercial and Medicare policies.
When an authorization program is administered by a vendor, they may use their own clinical criteria to make a medical necessity determination. For more information about specific delegated services, go to Clinical Resources>Prior Authorization.
For members enrolled in the Federal Employee Program (FEP), be sure to visit fepblue.org. On the Medical Policies and Utilization Management Guidelines page, click the tab, Utilization Management Guidelines for guidelines including:
Policies for FEP members can differ substantially from policies for members of commercial or Medicare Advantage plans. Skillled Nursing Facility services for FEP Standard Option members are one example. Refer to the resources below for help following our guidelines.