CLV IntelligenceReimbursement Policy Evidence

Free tool · Medicare Advantage

Check a Medicare Advantage denial against Medicare’s coverage policies

Medicare Advantage plans must follow Medicare’s national coverage determinations and the coverage decisions of the local Medicare contractor for the area (42 CFR 422.582(b)↗). Enter the codes from a denial and we show which of those policies we hold for the service, whether the diagnosis is on their lists, and the CMS document for each. No signup.

This reports what Medicare’s policies list. It is not a coverage determination, and it does not tell you a denial was wrong. Whether a claim is payable depends on the full medical record, documentation, and the policy version in force on the date of service: we check the version in force today and say when it took effect. Enter codes only: no patient names, member IDs or dates.

No date of service needed. We check the policy versions in force today, and each result says when that version took effect, so you can compare it to your own date of service.

Plan type

Why a state, not a ZIP code

Medicare assigns its local contractors by state, so the state where the service was furnished decides which local policies apply. For equipment and supplies, the contractor follows where the beneficiary lives. A ZIP code would add nothing but a second lookup that could quietly pick the wrong contractor.