Clinical criteria are used to guide medical decisions regarding diagnosis, management and treatment in health care.
CommunityCare complies with coverage criteria in statutes, regulations, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs) and general coverage and benefit conditions in Original Medicare as interpreted by the Centers for Medicare and Medicaid Services.
Medicare Coverage Database Search
When coverage criteria are not fully established in Medicare statutes, regulations, NCDs or LCDs, CommunityCare utilizes coverage criteria based on current evidence in widely used treatment guidelines or clinical literature.
InterQual® Transparency
Supporting websites:
CommunityCare may use the following guidelines to support coverage determinations:
Clinical Reference Guidelines
CommunityCare has a partnership with Dominion to administer supplemental dental benefits for our Medicare Advantage plans. Dominion’s coverage policies can be accessed below.
Dominion Utilization Review Guidelines
CommunityCare has a partnership with Evolent to administer utilization management for Radiation and Medical Oncology for our Medicare Advantage and Commercial plans. Evolent’s coverage policies can be accessed below.
Evolent Policies