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Coverage summaries and policy guidelines for MA members - Chapter 5 2022 UnitedHealthcare Administrative Guide

Hierarchy of references/resources

We develop our MA Coverage Summaries and Policy Guidelines with the help of:

  1. National Coverage Determination (NCD) or other Medicare guidance, e.g., Medicare Policy Benefit Manual, Medicare Managed Care Manual, Medicare Claims Processing Manual, Medicare Learning Network (MLN) Matters Articles.
  2. Local Coverage Determination (LCD) and Local Policy Articles (A/B MAC and DME MAC).
  3. UnitedHealthcare Commercial Medical Policies/Coverage Determination Guidelines.

Coverage summaries and policy guidelines

Our MA plan Evidence of Coverage (EOC) and Summary of Benefits (SOB) list the member’s covered benefits, limitations and exclusions. We use our MA Coverage Summaries and Policy Guidelines to interpret benefits for our members. The policies are subject to change based on Medicare’s coverage requirements, clinical evidence, technology and evolving practice patterns. You are responsible for reviewing the CMS Medicare coverage guidance documents. If there is a conflict between our policies and the guidance documents, the CMS information controls. Our MA Coverage Summaries and Policy Guidelines are available on: uhcprovider.com/policies > Medicare Advantage Policies.

Coverage summary and policy guideline updates

We publish monthly editions of the Medicare Advantage Coverage Summary and Policy Guideline Update Bulletins. These online resources provide notice to our network providers of changes to MA Coverage Summaries and Policy Guidelines. The bulletins are posted on the first calendar day of every month on:

A supplemental link to the policy updates announced in the Medicare Advantage Coverage Summary and Policy Guideline Update Bulletins is also available at UHCprovider.com/news.