Medicare Advantage Coverage Policies and Guidelines
The Coverage Summaries are policies based on existing current Medicare National Coverage Determinations, Local Coverage Determinations, CareFirst Medical Policies, and applicable CareFirst BlueCross BlueShield Medicare Advantage Plans EOCs and SOBs intended to provide benefit coverage information and guidelines specific to CareFirst BlueCross BlueShield Medicare Advantage Plans. Benefit interpretations for CareFirst BlueCross BlueShield Medicare Advantage Plan members are made on a case-by-case basis using the guidelines in the Coverage Summaries. The Coverage Summaries are subject to change based upon changes in Medicare's coverage requirements, changes in scientific knowledge and technology and evolving practice patterns.
Providers are responsible for reviewing the CMS Medicare Coverage Center guidance and in the event that there is a conflict between the Coverage Summaries and the CMS Medicare Coverage Center guidance, the CMS Medicare Coverage Center guidance will govern.
Medicare Advantage Coverage Summaries Terms and Conditions
- CMS National Coverage Determinations
Search for medical procedures under "Start your search." - CMS Local Coverage Determinations
Search for medical procedures under "Start your search." - CMS Medicare Benefit Policy Manual
- MCGTM Guidelines for CareFirst Medicare Advantage Core and Enhanced and Group Advantage Members
MCG Guidelines are proprietary and therefore, must be accessed using a secure log-in process. Please log into the CareFirst member portal and click on the Document Tab, Other Documents to view the Clinical Guidelines. - MCGTM Guidelines for CareFirst Advantage DualPrime Members
MCG Guidelines are proprietary and therefore, must be accessed using a secure log-in process. Please log into the CareFirst MyHealthPortal and click on the Resources Tab. - MCGTM Guidelines for CareFirst Medicare Advantage Core and Enhanced and Group Advantage Providers
MCG Guidelines are proprietary and therefore, must be accessed using a secure log-in process. Please log into the CareFirst Provider Portal and click on the Resources Tab. - MCGTM Guidelines for CareFirst Advantage DualPrime Providers
MCG Guidelines are proprietary and therefore, must be accessed using a secure log-in process. Please log into the CareFirst Advantage DualPrime Provider Portal and click on the Resources Tab. - CareFirst BlueCross BlueShield Medicare Advantage Utilization Management Policies
- CareFirst Part B Prescription Drug Coverage Policies and Criteria– CareFirst BlueCross BlueShield Advantage Core and Enhanced (H6067) and CareFirst BlueCross BlueShield Group Advantage (H7379)
- CareFirst Part B Prescription Drug Coverage Policies and Criteria – CareFirst BlueCross BlueShield Advantage DualPrime (H8854)
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