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BayCarePlus complies with general coverage and benefit conditions included in Traditional Medicare Laws, unless superseded by laws applicable to Medicare Advantage plans.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

Some Medicare benefits do not have applicable Medicare NCDs, LCDs, or specific traditional Medicare coverage criteria fully established in applicable Medicare statute or regulation. In this case, BayCarePlus may develop its own internal coverage criteria to use when making medical necessity determinations. 

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 and Part D benefits:

• Delta Dental
• MedImpact
• Mercy Behavioral Health