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Prior Authorization Texas Independence Health Plan I-SNP and IE-SNP

Medical Necessity

“Medically Necessary” or “Medical Necessity” means health care services or supplies that a physician, exercising prudent judgement, would provide and/or order for a patient. The services must be:

  • in accordance with generally accepted standards of medical practice;
  • clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and
  • not primarily for the convenience of the patient, physician, or other health care provider, and
  • not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury, or disease

Texas Independence Health Plan utilizes the following Medical Necessity criteria to guide utilization management decisions. This may include, but is not limited to, decisions involving inpatient reviews, prior authorizations, level of care, and retrospective reviews.

Medicare Part A Skill in Place/Skilled Nursing Facility

As a company, Texas Independence Health Plan has made the decision to strictly follow Medicare Benefit Manual, Chapter 8 for all Skilled in Place/Skilled Nursing Facility Authorization Request decisioning.

Medicare Part B Outpatient

Medicare Advantage medical policies identify the clinical criteria for determining when medical services are considered ‘reasonable and necessary’ (medically necessary). Medicare Advantage plans are required by CMS to provide the same medical benefits to Medicare Advantage members as original Medicare. As such, whenever possible, Medicare Advantage medical necessity decisions are based on Medicare coverage manuals, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) used in conjunction with an LCD, when available.

If there is no applicable NCD, LCD, or LCA (used in concert with an LCD), for the service under review, then other evidence-based criteria may be applied. In addition, each member’s unique clinical situation is considered in conjunction with current CMS guidelines.

The following hierarchy is used to determine Medicare Advantage Medical Policy:

  1. National Coverage Determinations (NCD) a) Local Coverage Determinations (LCD) b) Local Coverage Articles (LCA), when used in conjunction with LCD
  2. CMS Coverage Manuals or other CMS-Based Resource: Coverage provisions in interpretive manuals are instructions that are used to further define when and under what circumstances items or services may be covered (or not covered)
  3. In circumstances when Medicare guidelines are not available the Plan will utilize clinical criteria from outsource vendors Interqual and other approved Evidence Based Resources and Medical Literature.

Please see the links below to access the Clinical Determination Criteria information listed above:

Medicare Coverage Database Search (NCDs, LCDs, LCAs) MCD Search

Medicare Internet-Only Manuals (IOMs) Internet-Only Manuals (IOMs) | CMS

Interqual

To access the Interqual guidelines used by Texas Independence Health Plan you can create an account and access the information at the following link: https://prod.ds.interqual.com/service/connect/transparency?tid=faa0bf1e-cab7-457b-ad5f-e35b8f25ed33

Please be aware that planned hospitalizations for elective procedures and surgeries are reviewed per the “CMS Inpatient Only List Addendum E”. Procedures that are payable only as inpatient are provided on this list and are approved for inpatient level of care as prescribed by CMS. You may access a list of the 2024 procedures here.

Texas Independence Health Plan Medical Necessity criteria does not supersede state or Federal law or regulation.

 

Definitions

Internet Only Manual (IOM): The Internet-only Manuals (IOMs) are a replica of the Agency’s official record copy. They are CMS’ program issuances, day-to-day operating instructions, policies, and procedures that are based on statutes, regulations, guidelines, models, and directives. The CMS program components, providers, contractors, Medicare Advantage organizations and state survey agencies use the IOMs to administer CMS programs. They are also a good source of Medicare and Medicaid information for the public.

National Coverage Determination (NCD): a decision by Medicare and their administrative contractors that provide coverage information and determine whether services are reasonable and necessary. These guidelines apply across the United States wherever Medicare provides health coverage.

Local Coverage Determination (LCD): a decision by Medicare and their administrative contractors that provide coverage information and determine whether services are reasonable and necessary. These guidelines apply only to the areas of the country which the local Medicare Administrative Contractor, who author/adopts the LCD, has jurisdiction over.

Local Coverage Articles (LCA): Local Coverage Articles are a type of educational document published by the Medicare Administrative Contractors (MACs). Articles often contain coding or other guidelines that are related to a Local Coverage Determination (LCD).

Last Updated: 11/12/2024

Texas Independence Health Plan is a HMO-SNP with a Medicare contract. Enrollment in Texas Independence Health Plan depends on contract renewal. H5015_TIHPWEB_2025