Medicare provides guidelines and policies guiding coverage of many medical services and treatments. These Medicare policies include laws, regulations, national coverage determinations, local coverage determinations, and general coverage guidelines in traditional Medicare (collectively referred to as “Medicare guidelines”).
When Medicare guidelines are not fully established, in accordance with Medicare rules, Troy Medicare and/or our contracted third-party entities may develop and/or adopt additional coverage criteria and policies based on current, evidence-based treatment guidelines of public health and health research organizations, and recommendations of leading national health professional organizations.These policies and decisions reflect our medical review of currently available clinical information, including:
- Evidence-based treatment guidelines of public health and health research organizations
- Evidence-based treatment guidelines and positions of leading national health professional organizations
- Regulatory status of devices and technology
- Research published in peer-reviewed medical literature
- Expertise of physicians practicing in relevant clinical fields
- Other relevant clinical factors and information
Troy’s medical policies do not fully describe or authorize benefits and they do not guarantee coverage or payment. Coverage decisions and benefits are determined by multiple factors including the terms and conditions of the applicable benefit plan. Exclusions and limitations may apply.
- Declaration of Disaster or Emergency
- Clinical Guidelines for Inpatient Stays
- Denials and Terminations
- Part C Retrospective Review
- Post-Stabilization Policy
- Re-openings for Organization Determinations
- Medical Necessity Guidelines for Coverage Determination
- Lack of Clinical Information Policy
- Medical Necessity Review Personnel
- Timeframes for Review Policy
- Credentialing Committee
- Health Risk Assessment Policy
- Transition of Care Policy
- Outreach and Unable to Contact
- Interdisciplinary Care Team Policy
- Individualized Care Plan Policy
- Inpatient Readmission Policy
- PCP Selection, Assignment and Attribution
- Utilization Management Committee
- Remote Patient Monitoring Clinical Policy
- Prior Authorization Organization Determinations
Documents and Forms
Want to sign up for a plan? Need to share your health information with a loved one? We've got forms for all that and more.