Medicare Criteria

Medicare Criteria

All Medicare plans require that you follow certain developed criteria that require prior authorization. You can access and read about the latest updates on Original Medicare coverage guidelines for National Coverage Decisions (NCD) and Local Coverage Decisions (NCD) at any time. The following Capital Health Plan Medicare Advantage (HMO) developed criteria below require prior authorization:

• Anethesia and Facility Charges for Dental Services
• Implantable Hearing Devices
• Long Term Acute Care Hospitalization
• Skilled Nursing Facilities
• Thoracic Outlet Syndrome
• Wound Treatment Centers

In coverage situations where there is no Medicare NCD, LCD, Article or Coverage Rule, services will be reviewed using the applicable Blue Cross Blue Shield of Florida medical coverage guideline.
Reference-Medicare Managed Care Manual - Chapter 4, Section 90.5

Original Medicare Criteria

Capital Health Plan follows Original Medicare coverage policies for our Medicare members. You can access Original Medicare's coverage policies in the list below at any time.

For coverage policies that contain a Certificate of Medical Necessity (CMN) you may complete the CMN in lieu of submitting records and fax it to Capital Health Plan's Care Coordination Department at (850) 383-3310.

Prior Authorization

Effective 1/1/2017, the Florida Legislature requires all insurers to use the Universal Prior Authorization Form. Therefore, Capital Health Plan will only accept this form when submitted and completely filled out as directed by the instructions. Incomplete forms will not be considered a valid request for services and therefore will not be processed. This form may also be used for Medicare members, but it is not a requirement.

Download the Universal Prior Authorization Form