Provider Resources
Utilization Management Criteria and Policies
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:
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InterQual Transparency Tool
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National Comprehensive Cancer Network
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Pain Management Referral Policy
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Policy for Mechanical Stretching Devices
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Policy for Proton Beam Radiotherapy
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Policy for Intrauterine Device for Endometrial Hyperplasia
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Policy for DRG Audits
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Policy for Pyridoxine Hydrochloride Injection
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Policy for Levocarnitine Injection
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