Medicare local coverage determinations (LCDs)
Applicable services
Priority Health Medicare Advantage plans must provide members with all services covered by Original Medicare Parts A and B. The exceptions, which remain payable by Original Medicare but are not paid for by Priority Health Medicare1, are:
- Hospice care
- Inpatient hospital stays when enrollment ends
- Clinical trials
In providing Part A and Part B coverage, we must ensure that coverage is consistent with general coverage guidelines included under Original Medicare in its manuals and instructions unless superseded by a Center for Medicare & Medicaid Services (CMS) instruction or regulation concerning Medicare Advantage ("Part C") plans.
Medicare payment policy
Priority Health Medicare applies Medicare medical policy as found either under National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs)2.
If a service classified by Original Medicare as a benefit is described in an LCD under Medicare Part C rules, the LCD must have been written by a local Medicare Administrative Contractor (MAC) with "jurisdiction for claims in the geographic area in which services are covered under the Medicare Advantage (MA) plan."3
Priority Health is a local MA plan and applies the coverage policy of the A/B MAC with jurisdiction over the state in which the service is furnished to the enrollee.
Provider disputes
Providers who dispute the use of a particular LCD can file an appeal. Go to information on Medicare payment disputes and appeals.
If you dispute our use of one of the intermediaries identified above by citing another intermediary's LCD, you should also submit other supporting information for us to consider in making a decision.
1See Section 10.2, Basic Rule, Chapter 4, Medicare Managed Care Manual.
2See Section 80 et al, National and Local Coverage Determinations, Chapter 4, Medicare Managed Care Manual.
3See Section 80.1, Chapter 4, Medicare Managed Care Manual.