Reimbursement Policy Evidence, held the way an appeal needs it.

Why this exists

A Medicare Advantage plan must follow CMS’s national coverage determinations and the local contractor’s written coverage decisions. The evidence for an appeal is therefore public — but CMS serves only the current version of each policy, and a policy that changed between the date of service and the appeal can prove the wrong thing. The version that bound the plan on the day the service was furnished is what matters, and once it is replaced it is gone from the public web.

The company grew out of nearly fifteen years in medical devices — cancer diagnostics, orthopedics, infectious disease — where whether a test or device got paid came down to coverage policy that shifted continuously and was never held anywhere as it had stood. CLV Intelligence captures it as it is published, keeps every version, and links each one to the CMS document it came from.

How we work

We work with practices and with billing and revenue-cycle companies, never with patient data. A practice runs the free authorization check and, on the practice plan, logs its requests from the check, tracks each provider toward the prior-authorization exemption with a weekly standing email, and resubmits with the governing policy quoted. A billing company sends denials — a five-column file (codes, state, setting, date of service) that is read in its own browser, so no date of service reaches us — and receives, per line, a grounded appeal packet or a refusal receipt naming the gap, with nothing charged for a refusal. Both paths are on How we work.

Where the data comes from

Every record is read from a government source: the CMS Medicare Coverage Database, which is where all 16 Medicare Administrative Contractor jurisdictions publish their coverage determinations; CMS transmittals, fee schedules and NCCI edits; the Federal Register; the OIG; the FDA; and the Medicare Advantage Plan Benefit Package filings. We poll no contractor or payer site for coverage policy. The 9 source families, what each one contributes, and the live capture cadence are on Data sources and Archive status.

What we will not do

• · Say a claim is covered, or that a denial was wrong. We report what the policy lists and link the document.
• · Assert a code, a date or a coverage status the policy’s own text does not state.
• · Touch patient data. It never reaches us.
• · Give legal, billing or coding advice.

The rules behind those sentences, and how each record is captured, dated and verified, are on Methodology.