These reimbursement policies apply to Medicare Advantage plans.
Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Payments for claims may be subject to limitations and/or qualifications. Payment will be determined based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Providers and their office staff are encouraged to use self-service channels to verify member eligibility.
Decision making for Medicare Advantage is based upon the following hierarchy.
National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) can be found at www.CMS.gov. Please refer to the Coverage Determinations for Medicare Advantage policy for additional information on this process. The clinical rationale used by CareSource for making health coverage determinations is available by calling or faxing the CareSource Medical Management Department.
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.