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Clinical Policy Guidelines
Clinical Guidelines – Medicare (NCD/LCD) & Elite Health Plan Utilization Management Policies
At Elite Health Plan, we are committed to ensuring our members receive high-quality care and services.
This page provides information on coverage assessments, including Medicare National Coverage Determinations (NCDs) and Medicare Local Coverage Determinations (LCDs). These determinations are made by Medicare and its administrative contractors to establish whether a service or treatment is considered reasonable and necessary. NCDs and LCDs are based on evidence-driven processes and include opportunities for public input.
In situations where no specific Medicare statutes, regulations, NCDs, or LCDs outline coverage criteria, Elite Health Plan applies internal guidelines. These supplemental policies are developed using widely recognized clinical standards and utilization management practices to support our prior authorization process.
Our goal is to ensure that services provided are medically appropriate, cost-effective, and designed to meet the functional needs of our members while enhancing their overall health outcomes.
Your Evidence of Coverage indicates which services and items require a prior authorization or referral. Most times this will be managed through your Primary Care Provider or Specialist. If you would like to request a prior authorization for a medical service of supply, please see the prior authorization request form under Member / Forms & Resources.
Medicare Coverage Database where you can search what Medicare Covers.
Medicare National Coverage Determinations (NCDs)
Part A NCD (Hospital) | Part B NCD ( Medical Provider Services)
A National Coverage Determination (NCD) is a decision by Medicare that specifies whether certain treatments, procedures, or services will be covered for specific medical conditions. These decisions apply nationally, and all Medicare contractors are required to follow NCDs.
Medicare Local Coverage Determinations (LCDs)
Part A LCD (Hospital) | Part B LCD (Medical Provider Services)
Local Coverage Determinations (LCDs) are decisions made by Medicare Administrative Contractors (MACs). These determinations decide whether a service or item will be covered within a MAC’s specific jurisdiction (region), in accordance with section 1862(a)(1)(A) of the Social Security Act.
Elite Health Plan Clinical Policy Guidelines
Elite Health Plan’s policies are developed and approved by our Utilization Management Committee. These guidelines are designed to ensure that services provided to our members are: medically reasonable and evidence-based, cost-effective and appropriate for clinical needs, aimed at preventing harm and reducing barriers to care, supportive of functional independence, and focused on improving both clinical outcomes and overall quality of life.