Pay BillIndependent Health has developed clinical guidelines to establish evidence-based clinical criteria for utilization management decisions. We may delegate utilization management decisions of certain services to third-party organizations which may adopt their own clinical criteria.
Clinical guidelines apply to certain policies. Clinical guidelines apply to members enrolled in Medicare Advantage plans only if there is no criteria for the specific service in a Centers for Medicare & Medicaid Services (CMS) National Coverage Determination (NCD), Local Coverage Determination (LCD), or Local Coverage Articles (LCAs) on the date of a prior authorization request. View the NCDs, LCDs, and LCAs on CMS’ Medicare Coverage Database. Step therapy may be required in addition to NCD/LCD/LCA requirements.
Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals.
Coverage of services is subject to the terms, conditions, limitations of a member’s policy and applicable state and federal law.
If you have questions or need policy information
To confirm coverage or eligibility, please refer to your coverage policy documents (e.g., Certificate/Evidence of Coverage, Schedule of Benefits) or contact Independent Health.
Looking for medical related information? View our Medical Policies and Guidelines.