CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medicare Advantage policy hierarchy for NCDs and LCDs

Defines how Blue Cross & Blue Shield of Rhode Island (BCBSRI) makes coverage determinations for Medicare Advantage members by following CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), MAC jurisdiction rules, and peer-reviewed evidence when no CMS determination exists. Explains applicability, prior authorization note, and provider responsibility to review CMS guidance.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedicare Advantage policy hierarchy for NCDs and LCDs

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 17, 2019

Next Review DateN/A

Key ActionProviders are responsible for reviewing and following current CMS payment policies, NCDs, LCDs and other CMS guidance when furnishing services to Medicare Advantage members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — brief reports has_material_change = false.

4Policy determination hierarchy steps

Rhode Island MACsMACs referenced

Coverage Summary

Defines how Blue Cross & Blue Shield of Rhode Island (BCBSRI) makes coverage determinations for Medicare Advantage members by following CMS National Coverage Determinations (NCDs) as the primary source, then applicable Local Coverage Determinations (LCDs) and Medicare Administrative Contractor (MAC) jurisdiction rules, and applying peer-reviewed scientific evidence when no CMS determination exists.

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Medicare Advantage Policy Hierarchy & Policy Production

Hierarchy for policy determinations

BCBSRI applies the following hierarchy for Medicare Advantage policy determinations:

ALL of the following

Primary source
- National Coverage Determinations (NCDs) are the primary source for policy determinations.
If there is no NCD and there is one Medicare Administrative Contractor (MAC) which has an LCD and exclusive jurisdiction for an item or service, BCBSRI utilizes that particular LCD (applies when there is only one provider/laboratory for the particular item or service so the MAC for that region processes all claims for that item or service).
Jurisdiction for proprietary labs: Jurisdiction for proprietary laboratory services is normally the MAC serving the area where the laboratory is located; if a regional or national lab vendor has locations in various states, the LCD from the jurisdiction where the lab is headquartered is used.
If there is no NCD and no exclusive jurisdiction situation, BCBSRI utilizes the LCDs under the direction of the local Medicare Administrative Contractor (MAC) for Rhode Island's jurisdiction.
If there is no NCD, no exclusive jurisdiction situation, and no LCD from the Rhode Island regional MAC, BCBSRI will apply policy determinations developed using peer-reviewed scientific evidence.

Prior authorization and policy production

Prior authorization follows NCD/LCD: When a service requires prior authorization and CMS documented criteria in an NCD or LCD is being followed, a BCBSRI policy may not be produced.
See Related Policies Section for further information.
Medical necessity/edits follow NCD/LCD: When a service follows the medical necessity and diagnosis edits identified in an NCD or LCD, a BCBSRI policy may not be produced.

Required Provider Actions & Prior Authorization

Documentation Required

Follow CMS policies and guidance

Providers are responsible for reviewing and following current CMS payment policies, NCDs, LCDs and other CMS guidance when furnishing services to Medicare Advantage members.

Prior Authorization

Prior authorization may not have separate BCBSRI policy

When NCD or LCD criteria apply and the service requires prior authorization, BCBSRI may not produce a separate policy; providers should follow the applicable NCD/LCD prior authorization requirements.

Definitions & Background

BCBSRI’s internally developed policies are based on published guideline statements, physician specialty society recommendations, and peer-reviewed scientific evidence linking services to improved patient outcomes.

For Medicare Advantage members, BCBSRI follows applicable CMS payment policies, NCDs, and LCDs; Medicare Advantage policies may differ from commercial plan policies and providers are responsible for following current CMS guidance. When CMS-documented NCD or LCD criteria apply (including prior authorization or medical necessity/diagnosis edits), BCBSRI may not produce a separate policy and will apply the CMS criteria.

Term	Definition
Local Coverage Determinations (LCD)
A decision by a Medicare Administrative Contractor whether to cover a particular service on a MAC-wide basis; may include CPT/HCPCS and ICD-10-CM code lists.
Medicare Administrative Contractor (MAC)
Private organizations contracted with CMS that carry out administrative responsibilities for Medicare Parts A and B and have geographic jurisdiction.
National Coverage Determinations (NCD)
CMS determinations that outline the extent to which specific services are considered reasonable and necessary for Medicare coverage on a national basis.