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Coverage Determination

Provider Type

  • Participating Physician Groups (PPG)

All delegated participating physician groups (PPGs) that make coverage determinations for Health Net Cal MediConnect members must follow the criteria of medical hierarchy, as follows, to determine medical necessity:

  1. Medicare National Coverage Determinations (NCDs).
  2. Medicare National Coverage Determinations (NCD) Manual (Publication 100-03).
  3. Medicare Local Coverage Determinations (LCDs).
  4. Medi-Cal online Provider Manual (Part 2) for Medi-Cal based benefits
  5. Other evidence-based clinical criteria, such as Health Net national medical policies and delegated PPG criteria.

Benefit coverage follows Medi-Cal and Medicare coverage guidelines unless otherwise specified in the member's Cal MediConnect Member Handbook, such as carve-outs that may apply for vision, acupuncture or dental. In order to be eligible for coverage under Cal MediConnect, all services must meet applicable criteria for medical necessity.

Medi-Cal Only Provider Manual

To determine medical necessity for Medi-Cal benefits, the provider manual is an online multi-part resource that contains specific Medi-Cal program policies and prior authorization criteria.

Medicare National Coverage Determinations

To determine medical necessity for Medicare benefits, providers must first consult Medicare NCDs. NCDs are located on the Centers for Medicare and Medicaid Services (CMS) website at www.cms.gov/mcd by:

  1. Selecting documents to view.
  2. Selecting the region in which the service is performed.
  3. Searching by keyword, phrase or procedure codes.

Providers may use criteria from this page to state whether a specific request is a covered medical benefit or to support the medical necessity decision. If there is no documented NCD, providers must determine medical necessity by referring to the next step in the hierarchy, which is the NCD Manual.

The NCD Manual describes whether specific medical items, services, treatment procedures, or technologies are covered under Medicare. The manual is located on the CMS website. If a service is not specifically listed in the NCD Manual, providers must determine medical necessity by referring to the next step in the hierarchy, the LCDs.

Medicare Local Coverage Determinations

LCDs are written coverage decisions of local Medicare Administrative Contractors (MACs) with jurisdiction for claims in the geographic area in which services are covered under Health MA plans. Medicare LCDs apply to members in specific regions. Accompanying articles are used in conjunction with LCDs and are not meant to be used alone. LCDs are located on the CMS website at www.cms.gov/mcd by:

  1. Selecting documents to view.
  2. Selecting the region in which the service is performed.
  3. Searching by keyword, phrase or procedure codes.

Providers may use criteria from this page to state whether a specific request is a covered medical benefit or to support the medical necessity decision. If a service is not specifically mentioned, providers must determine medical necessity via the next step in the hierarchy, evidence-based clinical criteria (such as Health Net national policies or delegated PPG clinical criteria).

An MAC outside of the plan's service area sometimes has exclusive jurisdiction over a Medicare-covered item or service. In some instances, one Medicare Part A and Part B MAC processes all of the claims for a particular Medicare-covered item or service for all Medicare beneficiaries around the country. This generally occurs when there is only one supplier of a particular item, medical device or diagnostic test (for example, certain pathology and lab tests furnished by independent laboratories). In this situation, delegated medical groups must follow the coverage requirements or LCDs of the MAC that enrolled the supplier and processes all of the Medicare claims for that item, device or test.

Health Net National Medical Policies

If providers do not find results from the Medi-Cal Provider Manual, NCDs, NCD Manual, or LCDs search, they should refer to the Health Net national medical policies. PPGs may access medical policies on the Health Net provider website at provider.healthnet.com by selecting Working With Health Net > Clinical > Medical Policies. Updated policies feature a grid and instructions that outline what resources can help to determine medical necessity. Resources are listed in the order they should be utilized. If a resource is blank, it may be due to the fact that at the time of writing or revising the policy no Medicare coverage criteria existed, in which case providers must conduct a more specific search of the NCDs, NCD Manual or LCDs.

Delegated PPG Criteria

If no results appear or the results are vague in the Medi-Cal Provider Manual, NCDs, NCD Manual, LCDs, and Health Net national medical policies, providers must search the individual PPG criteria set.

Documenting Medical Necessity

PPGs must thoroughly document the criteria they used to review for medical necessity (Medi-Cal Provider Manual, NCDs, NCD Manual, LCDs, Health Net national medical policy, or delegated PPG criteria). Documentation must be able to lead an auditor through the steps taken to prove medical necessity. If criteria are vague or unavailable, providers must follow internal policy and forward the inquiry to the medical director, including documentation of the sources reviewed and lack of criteria found.

Last Updated: 10/31/2019