Coverage, Claims & Billing

CMS Policies and Changes

National Coverage Determination (NCD)

The Centers for Medicare & Medicaid Services (CMS) sometimes changes the coverage rules that apply to an item or service under Medicare. Such changes may include what benefits and services are covered, what benefits and services are changing, and what Medicare will pay for an item or service. When this happens, CMS issues a National Coverage Determination or NCD. You can view the CMS annual database where all NCDs are posted by year here.

Utilization Management Criteria and Policies

The Centers for Medicare & Medicaid Services (CMS) is the government agency that manages Medicare Advantage plans throughout the United States. CMS limits Medicare coverage to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). They require health plans, like Viva Medicare, to base decisions about covering items, services, or medications on National and Local Coverage Determinations.

National Coverage Determinations (NCD) and Local Coverage Determinations (LCDs) are a general outline of coverage that is in place for all Medicare Advantage health plans. NCDs and LCDs are made through an evidence-based process.

When there are no National or Local Coverage Determination policies available, Viva Medicare is allowed to use other evidence-based, recognized coverage criteria, such as the National Comprehensive Cancer Network , or our vendor InterQual®. For the few services in which no criteria is available through these resources, CMS allows us to create an internal policy, using evidence-based sources.

Viva Health makes all of these criteria publicly available for anyone who wants to view them. The links to the resources are below:

If you have any questions or need help finding a specific criteria, please call Member Services at 1-800-633-1542, TTY: 711. Our hours are 8am - 8pm, Monday - Friday (from October 1 to March 31: 8am - 8pm, 7 days a week).