Lexology February 20, 2024
On February 6, 2024, the US Centers for Medicare & Medicaid Services (CMS) released a set of frequently asked questions (FAQs) related to Medicare Advantage (MA) coverage criteria and utilization management (UM) requirements. The FAQs provide guidance on new regulatory requirements regarding the use of internal coverage criteria for basic benefits, prior authorization, UM tools and more, which were outlined in an April 2023 final rule and went into effect for coverage beginning on January 1, 2024.
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USE OF AI IN COVERAGE DETERMINATIONS
Stakeholders have raised questions concerning the role of artificial intelligence (AI), algorithms and similar tools in making coverage determinations. This discussion has attracted more attention as new technologies emerge and expand across the industry. In...
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