Payer policies
US healthcare payer policies
Whether a claim gets paid depends on the payer's policy for that service: what it covers, what it needs to see in the record, which codes it accepts and whether it needs approval first. Every payer writes its own, and most publish several libraries, split by line of business and state.
This guide covers where Medicare, Medicaid plans and the major commercial payers publish their policies, what each kind of policy does, and how to find the version that applies to a claim.
Policies by payer
Official payer pages, checked Oct 25, 2026. Each payer page lists every library we link, with what it holds.
The kinds of payer policy
National coverage determinations (NCDs)
CMS decisions on whether Medicare covers an item or service nationwide. Every Medicare contractor must follow them.
Local coverage determinations (LCDs)
Coverage criteria written by one Medicare Administrative Contractor for its jurisdiction, each paired with a billing and coding article that lists the codes.
Commercial medical policies
A commercial payer's rules on when a service is medically necessary. Aetna calls them Clinical Policy Bulletins, Cigna calls them coverage policies, Anthem pairs medical policies with clinical UM guidelines.
Reimbursement and payment policies
How a covered service is paid: coding and modifier rules, bundling, multiple-procedure reductions and billing requirements.
Drug and pharmacy policies
Coverage criteria for drugs under the medical benefit and the pharmacy benefit, published alongside formularies.
Prior authorization lists
The services and codes that need approval before they are performed, usually published by plan type and often by state.
Medicaid and state plan policies
Medicaid managed care plans publish policies per state, on top of the state Medicaid agency's own manuals.
Worked example: one service, 7 Medicare contractors
Even inside Medicare, coverage can depend on where you bill. For facet joint interventions for pain management, 7 Medicare Administrative Contractors each publish their own LCD, with 8 billing and coding articles carrying the codes. 2 of the LCD records have a future effective date, so a revised version is already published but does not apply yet.
A claim from a practice in one jurisdiction is judged against that contractor's LCD, not its neighbor's. The topic page puts them side by side, with each LCD's status and a link to the record on cms.gov.
See every LCD for facet joint interventions for pain managementSource: CMS Medicare Coverage Database, snapshot Oct 25, 2026.
How payer policies change
Policies are revised all the time, and most payers announce the changes on a schedule. UnitedHealthcare publishes a policy update bulletin on the first calendar day of every month. Cigna posts a monthly policy update document. CMS says the downloadable Medicare Coverage Database data is refreshed weekly.
The date that matters is the date of service. A policy revised after the service was performed usually does not apply to it, and a finalized LCD in its notice period does not apply until its effective date.
Reading a policy against a claim
- Find the right library. Use the payer, the member's line of business (commercial, Medicare Advantage, Medicaid, Exchange) and the state.
- Pick the version in effect. Match the policy's effective dates to the date of service.
- Check the codes. Confirm the procedure codes are in scope and the diagnoses on the claim are ones the policy accepts. For Medicare LCDs these are in the billing and coding article.
- Check the documentation. Medical necessity criteria usually spell out what the record has to show.
- Check prior authorization separately. It lives on its own list, and approval does not replace meeting the policy.
Where RCIntel fits
RCIntel keeps payer policy in a form software can use. Medicare NCDs and LCDs (345 NCDs and 955 LCD records today) back Coverage Check, which tells you line by line whether a claim's diagnoses support Medicare coverage. RCIntel's policy library also holds posted commercial and Medicaid policies from UnitedHealthcare, Aetna, Anthem and Humana, and every answer links to the source document.
For any other policy, upload the PDF to Payer Intelligence and ask it questions; answers cite the section and page they came from. The same knowledge is available over REST and MCP for teams building their own software.
Common questions
Where do payers publish their medical policies?
On their provider websites. Medicare coverage policy is in the CMS Medicare Coverage Database. Commercial payers publish policy libraries by line of business, and Medicaid plans usually publish one library per state. Each payer page here links the official libraries.
Why can two payers cover the same service differently?
Each payer writes its own medical policy, and Medicare's local policies differ by contractor. The same procedure can have different medical necessity criteria, documentation requirements and covered diagnoses depending on the payer, the member's plan and the state.
How do I find the policy version that applies to a claim?
Use the version in effect on the date of service. Payers publish effective dates and update bulletins; Medicare LCDs show a future effective date during their notice period, so a newer version may not apply yet.
Is a medical policy the same as a prior authorization requirement?
No. A medical policy says whether a service is covered and when it is medically necessary. A prior authorization list says which services need approval before they are performed. A service can need prior authorization and still be denied if the medical policy criteria are not met.
Payer policies are published by each payer and change often. Links here go to the payer's own pages; confirm the current version there before billing.