BayCarePlus Medical Criteria Policy

BayCarePlus relies on several resources to determine whether a service or procedure is covered under a BayCarePlus Plus member's benefit plan and is medically necessary:

Center for Medicare and Medicaid (CMS) Criteria

BayCarePlus complies with general coverage and benefit conditions included in Traditional Medicare Laws, unless superseded by laws applicable to Medicare Advantage plans. BayCarePlus Plus also follows national coverage determinations (NCDs) and local coverage determinations (LCDs); these coverage policies can be found in the Medicare Coverage Database (MCD).

Internal Coverage Criteria

BayCare Health Plans utilizes InterQual criteria in circumstances where there are no applicable Medicare statutes, regulations, NCDs or LCDs. A link to the applicable InterQual criteria can be found below.

InterQual®

In the event of a conflict, the LCD, NCD, or Internal Coverage Criteria policy will supersede InterQual® guidance. To access InterQual® criteria, create a user account or log in here: InterQual®

Clinical Practice Guidelines

BayCarePlus annually adopts clinical practice guidelines from national organizations that serve as an authority on the subject matter. 

Delegates

BayCarePlus delegates also follow clinical guidelines to make medical necessity determinations related to behavioral health services: