Services will be reviewed according to the Medicare Coverage Guidelines, established by the Centers for Medicare & Medicaid Services (CMS). According to the guidelines, all medical care, services, supplies and equipment must be medically necessary.
In scenarios where CMS does not provide guidance on the particular medical care, service, supplies and equipment, Prevea360 Medicare Advantage Health Plan will use MCG (formerly Milliman Care Guidelines) criteria or a Prevea360 Medicare Advantage Medical Policy. See the Prevea360 Medicare Advantage Medical Services Prior Authorization List to access the Prevea360 Medicare Advantage Medical Policies relevant to the services you are requesting.
Additional Information about medical management can be found on the Prevea360 Health Plan Medical Management page. Key resources include: