Benefit coverage follows Medicare coverage guidelines unless otherwise specified in the member's Evidence of Coverage (EOC), such as carve-outs that may apply for vision, acupuncture or dental. In order to be eligible for coverage under Medicare, all services must meet applicable criteria for medical necessity.

To determine medical necessity, providers must first consult Medicare NCDs, which apply to Medicare members in all regions. NCDs are located on the Centers for Medicare and Medicaid Services (CMS) website at www.cms.gov by:

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 at www.cms.gov. 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.

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 Net's 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 by:

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 PPGs 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.

Other evidence-based clinical criteria include Health Net national medical policies and delegated PPG criteria.

If providers do not find results from the 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 under Resources for You.  Updated policies feature a grid and instructions that outline what resources can help to determine medical necessity. Resources are listed in the order that 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 site.

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

PPGs must thoroughly document the criteria they used to review for medical necessity (NCDs, NCD Manual, LCDs, Health Net national medical policies, 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.

Integrated organization determination for DSNP members in Exclusively Aligned Enrollment (EAE) counties

Dual Special Needs Plan (DSNP) contractors are required to provide integrated organization determination for the DSNP members in Exclusively Aligned Enrollment (EAE) counties.For DSNP members in EAE counties, the authorization for the services requested need to be reviewed for both Medicare and Medi-Cal benefits to determine eligibility for the service requested. PPGs that are delegated to perform the Medicare services shall not deny prior authorization as “not a covered benefit” without checking both Medicare and Medi-Cal covered services (refer to the list of services below).

DSNP prior authorization timelines

PPGs should forward prior authorizations for the services that are not covered under Medicare but that are covered under Medi-Cal to Health Net within the following timelines:

• For standard requests, forward to Health Net within 1 business day upon receipt of the request.
• For expedited requests, forward to Health Net within 24 hours upon receipt of the request.

Fax authorizations to Health Net Medi-Cal Prior Authorization Department fax number

Fax prior authorizations to the Medi-Cal fax number listed under Health Net Prior Authorization Department in the Provider Library’s Contacts section and include:

• The date and time that the service request was initially received.
• The clinical decision that was used to make the initial determination.

Services not covered under Medicare but covered under Medi-Cal

• Asthma remediation
• Community Based Adult Services
• Community Supports
• Community transition services/nursing facility transition services to a home
• Day habilitation programs
• Durable medical equipment (DME) that is covered by Medi-Cal
• Environmental accessibility adaptation (home modification)
• Housing deposit (up to $6,000)
• Housing tenancy and sustaining services
• Housing transition navigation
• Long-term care
• Medically tailored meals
• Nursing facility transition/diversion to assisted living facilities
• Personal care services and homemaker services
• Recuperative care
• Respite services
• Short-term post-hospitalization housing
• Sobering centers

Scenarios where PPGs would be responsible for sending out the Applicable Integrated Plan (AIP) Coverage Decision Letter

Refer to the below table to see the scenarios where PPGs are responsible for sending out the AIP Coverage Decision Letter. This will help PPGs determine when to forward the authorizations to the Plan and when to send the Applicable Integrated Plan Coverage Decision Letter for DSNP members in EAE counties.

Scenarios where PPGs would be responsible for forwarding the request to the Health Plan

The Applicable Integrated Plan Coverage Decision Letter can be found in the Delegation Oversight Interactive Tool (DOIT) /MetricStream.