Medicare Advantage Plans Adherence to Local and National Coverage Determination Inquiries

Published 07/20/2023

The Centers for Medicare & Medicaid Services (CMS) Internet Only Manual, Publication 100-16, Chapter 4, Section 10.2 (PDF) states, "MA plans must provide their enrollees with all basic benefits covered under original Medicare." Sections 90.3 through 90.4.2 (PDF) outline Medicare Advantage (MA) plans requirements regarding National and Local Coverage Determinations.

Providers are required to make inquiries regarding MA plan coverage directly to the patient’s individual plan and, if desired, discuss any appeal or grievance rights afforded a specific claim. Palmetto GBA, as the Medicare Administrative Contractor MAC for traditional Medicare Parts A, B and home health and hospice is unable to assist with these inquiries.

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