Medicare Advantage (MA) Plans Adherence to Local and National Coverage Determination Inquiries

Published 01/12/2018

The Centers for Medicare & Medicaid Services (CMS) Internet Only Manual, Publication 100-16, Chapter 4, Section 10.2 (PDF, 522 KB) states: 'MA plans must provide their enrollees with all basic benefits covered under original Medicare.' Sections 90.3 through 90.4.2 (PDF, 426 KB)outline Medicare Advantage Plans requirements regarding National and Local Coverage Determinations.

Providers are required to make inquiries regarding Medicare Advantage Plan coverage directly to the patient’s individual Advantage 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 Part A, B and Home Health and Hospice is unable to assist with these inquiries.

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