Medical Necessity Considerations: General

As a Medicare Advantage organization, Blue Cross and Blue Shield of Nebraska (BCBSNE) is required by CMS to provide coverage to enrollees for all Part A and Part B Original Medicare covered services. However, CMS does not require that Medicare Advantage organizations follow the same payment determination rules or processes as Original Medicare does for providers.  

While BCBSNE does apply medical necessity criteria to determine coverage, the criteria does not have to be applied in the same manner as is required under Original Medicare. Specifically:  

• Benefits: Medicare Advantage plans must provide or pay for medically necessary covered items and services under Part A (for those entitled) and Part B.  
• Access: Medicare Advantage enrollees must have access to all medically necessary Part A and Part B services. However, Medicare Advantage plans are not required to provide Medicare Advantage enrollees the same access to providers that is provided under Original Medicare.  
• Billing and payment: Medicare Advantage plans need not follow Original Medicare claims processing procedures. Medicare Advantage plans may create their own billing and payment procedures as long as providers, whether contracted or not, are paid accurately, in a timely manner and with an audit trail. 

When determining medical necessity, both BCBSNE and Original Medicare coverage and payment are contingent upon a determination that all three of the following conditions are met:  

• A service is in a covered benefit category.  
• A service is not specifically excluded from Medicare coverage by the Social Security Act.  
• The item or service is “reasonable and necessary” for the diagnosis or treatment of an illness or injury or to improve functioning of a malformed body member or is a covered preventive service.