Blue Medicare PPO Coverage Resources
Providers participating in the Blue Medicare PPO network should refer directly to Medicare coverage policies when making coverage decisions. There are two types of Medicare coverage policies that apply:
- National Coverage Determinations (NCDs)
- Local Coverage Determinations (LCDs)
As a Medicare Advantage plan, Blue Medicare PPO must cover all services and benefits covered by Medicare. Coverage information that you receive concerning original Medicare also applies to Blue Medicare PPO.
National Coverage Determinations (NCDs)
The Centers for Medicare and Medicaid Services (CMS) explains NCDs through program manuals. Key manuals for coverage include:
- Medicare National Coverage Determinations Manual
- Medicare Program Integrity Manual
- Medicare Benefit Policy Manual
CMS updates program manuals through program transmittals and also sends updated information via articles through the Medicare Learning Network.
Local Coverage Determinations (LCDs)
CMS contractors (e.g., carriers and fiscal intermediaries) develop and issue local coverage determinations (LCDs) to provide guidance to the public and provider community within a specific geographical area. LCDs supplement an NCD or explain when an item or service will be considered covered if there is no NCD. An LCD cannot contradict an NCD.
Providers may access our region's LCDs at the following web site addresses:
- Durable Medical Equipment (DMERC)
- Medicare Part B
- Medicare Part A
- Regional Home Health Intermediary (RHHI)
Providers are encouraged to join mailing lists at the above Medicare contractors' Web sites for LCD policy publications and at CMS's Web site for NCD policy publications. This can be done by going to each contractor's Web site (and CMS's Web site) and subscribing to their mailing lists.
Medicare Coverage Database
CMS launched the Medicare Coverage Database in December 2002. The following areas may be searched:
- National Coverage Determinations (NCD)
- National Coverage Analyses (NCAs) – These documents support the NCD process
- Local Coverage Determinations (LCDs) – This section of the Medicare Coverage Database is updated on a monthly basis. Therefore, the most current information should be accessed through the local Web sites listed above.
