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Clinical Determination Criteria and Medical Necessity

Medical Necessity

Medical Necessity means health care services or supplies that are
consistent with accepted medical standards, appropriate for the patient’s condition,
effective in diagnosing or treating an illness, injury, or disease, not primarily for
convenience, and provided in the most cost-effective manner expected to achieve the
same clinical outcome.

Clinical Determination Criteria

UM clinical staff use the following information, criteria, and hierarchy to make
medical necessity determinations:

CMS
- National Coverage Determination (NCD)
- Local Coverage Determination (LCD)
- LCDs outside of applicable Plan Service Area
- Medicare Benefit Policy Manuals, Transmittals and Publications
AAH Medical Coverage Policies (AAH-MCP)
Evidence Based Criteria
- MCG Care Guidelines
- Medicare Drug Compendia
Other Approved Evidence Based Resources and Medical Literature

Find more information about clinical determination criteria by clicking the links below:

Other Approved Evidence Based Resources and Medical Literature include:

MCG
Dental

Follow the instructions below to access the MCG Guidelines:

Step 1: Read the disclaimer and accept the terms and conditions.
Step 2: Complete the User Information Form.
Step 3: Complete the verification process to continue.
Step 4: Click on the arrow icon.
Step 5: Click on the guidelines you wish to view.

MCG Care Guidelines are protected by copyright and cannot be shared without permission.
Members and prospective members can view applicable guidelines online but cannot print them.

How to fill out the enrollment form

Who can use this form?

People with Medicare who want to join a Medicare Advantage Plan

To join a plan, you must:

Be a United States citizen or be lawfully present in the U.S.
Live in the plan’s service area

Important: To join a Medicare Advantage Plan, you must also have both:

Medicare Part A (Hospital Insurance)
Medicare Part B (Medical Insurance)

When do I use this form?

You can join plan:

Between October 15–December 7 each year (for coverage starting January 1)
Within 3 months of first getting Medicare
In certain situations where you’re allowed to join or switch plans

Visit Medicare.gov to learn more about when you can sign up for a plan.

What do I need to complete this form?

Your Medicare Number (the number on your red, white, and blue Medicare card)
Your permanent address and phone number

Note: You must complete all items in Section 1. The items in Section 2 are optional — you can’t be denied coverage because you don’t fill them out.

Reminders:

If you want to join a plan during fall open enrollment (October 15–December 7), the plan must get your completed form by December 7.
Your plan will send you a bill for the plan’s premium. You can choose to sign up to have your premium payments deducted from your bank account or your monthly Social Security (or Railroad Retirement Board) benefit.

What happens next?

Once they process your request to join, they’ll contact you

How do I get help with this form?

Call PruittHealth Premier at 1-855-855-0668 (TTY 711) 1-855-855-0759 (TTY 711) 1-855-855-0759 (TTY 711).

Or, call Medicare at 1-800-MEDICARE (1-800-633- 4227). TTY users can call 1-877-486-2048.

En español: Llame a PruittHealth Premier al 1-855-855-0668 (TTY 711) 1-855-855-0759 (TTY 711) 1-855-855-0759 (TTY 711) o a Medicare gratis al 1-800-633-4227 y oprima el 2 para asistencia en español y un representante estará disponible para asistirle.

Individuals experiencing homelessness

If you want to join a plan but have no permanent residence, a Post Office Box, an address of a shelter or clinic, or the address where you receive mail (e.g., social security checks) may be considered your permanent residence address.

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 0938-1378. The time required to complete this information is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) 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.

IMPORTANT Do not send this form or any items with your personal information (such as claims, payments, medical records, etc.) to the PRA Reports Clearance Office. Any items we get that aren’t about how to improve this form or its collection burden (outlined in OMB 0938-1378) will be destroyed. It will not be kept, reviewed, or forwarded to the plan. See “What happens next?” on this page to send your completed form to the plan.

We value you as a member and want to share how your benefits will change, starting April 1,2023.

Under the Part B Rebatable Drug Coinsurance Adjustment provision, beginning April 1, 2023, coinsurance for Part B rebatable drugs will be reduced, if the drug’s price has increased at a rate faster than the rate of inflation.

CMS will publish the adjusted beneficiary coinsurance for each Part B rebatable drug in the quarterly pricing files posted on the CMS website, as a 0-20% effective coinsurance of the Medicare-approved payment amount.

Part B rebatable drugs may be in either of the categories “Chemotherapy administration services to include chemotherapy/radiation drugs” or “Other drugs covered under Part B of original Medicare” listed in § 422.100(j)(1)(i). The list of Part B rebatable drugs as well as the effective beneficiary coinsurance for those drugs could change each quarter.

For questions about this document, please contact our Member Services number at 1-855-855-0668 (Georgia) and 1-855-855-0759 (North Carolina / South Carolina) for additional information. (TTY users should call 711). Hours are 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

June 1, 2023

We value you as a member and want to share how your benefits will change, starting July 1,2023.

Under the Part B Insulin Cost Sharing Cap, beginning July 1, 2023, Insulin furnished under Part B through an item of durable medical equipment covered under section 1861(n) (i.e., a medically necessary traditional insulin pump), is subject to a beneficiary coinsurance cap for a month’s supply of such insulin (that does not exceed $35 and the Medicare Part B deductible does not apply).

Please contact our Member Services number at 1-855-855-0668 (Georgia) and 1-855-855-0759 (North Carolina / South Carolina) for additional information. (TTY users should call 711). Hours are 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.