The below Medical Policies are applicable to VillageCareMAX Benefit Plans offered by VillageCareMAX.
| Product Line | Condition/ Disease/ Usage | Policy Type | Link |
|---|---|---|---|
| MLTC, MAP, Supplemental Benefit | Back Pain | Medical Policy | Click Here |
| MLTC | Wound Care / DME | Medical Policy | Click Here |
| All Medicare Products (Inpatient Only) | 30 Day Readmissions with Same or Similar Diagnoses | Payment Policy | Click Here |
| MLTC, MAP | Outpatient support for MLTC /MAP members in need of medically supported adult day services. | Medical Policy | Click Here |
| All Products | Accessing providers that are not participating in the VillageCareMAX network. | Payment Policy | Click Here |
| All Medicare Products (Inpatient Only) | Reimbursement for HACs | Payment Policy | Click Here |
| Medicare Part B | CMS regulation on the specific coverage of diabetic supplies for members | Medical Policy | Click Here |
| Medicare Part B | Outlines the coverage criteria and guidelines for the use of monoclonal antibodies directed against amyloid for the treatment of Alzheimer's Disease (AD) based on the guidelines set forth by the Centers for Medicare & Medicaid Services (CMS) | Medical Policy | Click Here |
| MAP | According to the Patient Protection and Affordable Care Act, health plans are required to cover "Routine Patient Costs" incurred by a "Qualifying Individual"Medicaid beneficiary who is participating in an "Qualifying "Approved Clinical Trial. | Medical Policy | Click Here |
| Medicare Part B | The primary purpose of this VillageCare Medicare Part B's injectable and infusion drug policy is to cover certain prescription drugs that are administered by a healthcare professional (e.g., physicians, hospitals) and are not typically self-administered, according to the Centers for Medicare & Medicaid Services (CMS). | Medical Policy | Click Here |
VillageCareMAX has developed Medical Policies to assist us in administering health benefits. These policies help to clarify the application of clinical coverage guidelines and medical appropriateness. Treating physicians and healthcare providers are responsible for determining what care to provide to their patients. Members should always consult their physician before making any decisions about medical care.
Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The member specific benefit plan document identifies which services are covered, which are excluded, and which are subject to limitations. In the event of a conflict, the member specific benefit plan document supersedes the Medical Policy. The Policies are not intended to be an expansion of benefits beyond the benefits specified in the member specific benefit plan document. For more information on a specific member's benefit coverage, please call the customer service number on the back of the member ID card.
VillageCareMAX follows Medicare and Medicaid coverage guidelines and regularly updates its Medical Policies to comply with changes in Centers for Medicare & Medicaid Services (CMS) policy/guidelines. Medical Policies are subject to change based upon changes in Medicare and state Medicaid coverage requirements, changes in scientific knowledge and technology, and evolving practice patterns. Providers are responsible for reviewing the CMS Medicare Coverage Center guidance. In the event there is a conflict between these policies and the CMS Medicare Coverage Center guidance, the CMS Medicare Coverage Center guidance will govern.
In the absence of an applicable National Coverage Determination (NCD), Local Coverage Determination (LCD), or other applicable Medicare guidelines, VillageCareMAX may develop and apply internal coverage criteria as referenced in our Medical Policies. Internal coverage criteria are based on current scientific evidence in clinical literature.
VillageCareMAX's Medical Policies do not denote what requires prior authorization and what does not. Please refer to the member handbook or the provider manual for more details.
Medical Policies are developed as needed, regularly reviewed and updated, and subject to change.
By reviewing this, you have agreed to abide by the above terms and conditions.
