| Name of Service |
Fully Established |
Fully Established Medicare Administrative Contractor (MAC) Jurisdictions |
Not Fully Established- No Applicable Medicare Rules (422.101(b)(6)(i)(C)) |
Not Fully Established- Interpretation Needed |
Not Fully Established- Flexibility Explicitly Allowed |
Internal Coverage Criteria |
Total Number of Internal Coverage Criteria Policies and Documents |
Previous Coverage Guidelines |
Organization or Vendor |
Internal Coverage Criteria Supported by Evidence |
Website Link(s) |
| Example 1 - BNP Testing |
Y |
J-15, J-J, J-M, J-N |
N |
Y |
N |
Y |
1 |
N |
Sample Medicare Advantage Organization |
Y |
www.sampleMAO.com/coveragecriteria/Lab Testing |
| Example 2 - MRI (head) |
N |
NA |
N |
Y |
N |
Y |
1 |
Y |
InterQual |
Y |
www.sampleMAO.com/coveragecriteria/Imaging |
| Example 3 - Inpatient hospital admission |
N |
NA |
N |
Y |
N |
Y |
8 |
Y |
Sample Medicare Advantage Organization, MCG, Apollo, Astrana |
Y |
www.sampleMAO.com/coveragecriteria/Hospital |
| Example 4 - Heart transplant |
Y |
All |
NA |
NA |
NA |
N |
2 |
N |
Sample Medicare Advantage Organization, MCG |
Y |
www.sampleMAO.com/coveragecriteria/Transplant, www.sampleMAO.com/coveragecriteria/Hospital |
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| According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is OMB 0938-New. This information collection will allow CMS to conduct a comprehensive review of Sponsoring organizations’ compliance with Medicare Part C utilization management (UM) requirements. The time required to complete this information collection is estimated at 410 hours per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is mandatory per CMS’s authority under Section 1857(d) of the Social Security Act and implementing regulations at 42 CFR § 422.503 and § 422.504, which state that CMS must oversee a Medicare Advantage (MA) organization’s continued compliance with the requirements for a MA organization. Additionally, per § 422.516(a), MA organizations are required to compile and report to CMS information related to the utilization of services, and other matters as CMS may require. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. |
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