Medicare Advantage Medical Coverage Policies - Frequently Asked Questions
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Answers to common questions about how Integrated Home Care Services (i Care) applies Medicare Advantage coverage determinations, how to find referenced policies and external criteria, and how to request interpreter services. Applies to providers and members interacting with i Care's prior authorization and coverage processes.
No material clinical or coverage changes in this revision.
Coverage Criteria
This FAQ does not specify any coverage criteria within the document. It is informational and explains how i Care determines which external or internal criteria were used to review a prior authorization request, and where providers can locate those criteria for review.
Provider Actions and Prior Authorization
Sources used for prior authorization reviews
Prior authorization reviews use criteria from CMS coverage determinations (NCD/LCD) and policies developed and approved by i Care's Utilization Management (UM) Committee; the PA determination letter will state which type of criteria was used and where to review it.
- Letter will state whether a CMS coverage determination (NCD or LCD) or an i Care policy was used.
- CMS NCDs/LCDs are available on CMS's Medicare Coverage Database.
Review the PA letter for the criteria and rationale
If you receive a denial or partial approval, review the PA determination letter for the named criteria and the stated clinical rationale so you can submit targeted additional information or file an appeal.
- The letter includes the name of the criteria used to review the request.
- Use the named criteria and the explanation provided to guide documentation or appeal submissions.
Locate referenced i Care policy
Denial or partial approval letters that reference an i Care policy will include the policy name and number; you can locate the full policy by searching Humana's Medical and Pharmacy Coverage Policies site using that name or number.
- Example format shown in letters: 'HUM-1033-003 - Capsule Endoscopy' (search by name or number).
- Humana's coverage policies apply to i Care as a Humana subsidiary.
Denial explanation and how to obtain referenced criteria
Denial or partial approval letters will state the name of the criteria used and provide an explanation of the clinical rationale; follow the letter's instructions to request a copy of external criteria (e.g., MCG) or to appeal.
- Letters name the criteria used by i Care's PA Department.
- For MCG criteria, follow the steps in the letter or call i Care's Prior Authorization Department at 414-299-5539 or 855-839-1032 to obtain a copy.
- For other questions, contact i Care using the phone number on the back of the member's ID card.
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