What criteria must be met for a service to be eligible for Medicare reimbursement?

For a service to be eligible for Medicare reimbursement, it is essential that the service meets three criteria: it must be considered medically necessary, covered under Medicare policy, and compliant with regulations.

Medically necessary means that the service is appropriate for the condition being treated and is not experimental or investigational. Coverage refers to whether the specific service is included within the list of benefits provided under Medicare guidelines. Compliance involves adherence to federal and state laws as well as Medicare policies regarding documentation and billing practices.

Evaluating the other criteria, while services performed by a physician may often be eligible for reimbursement, it is not a strict requirement as other qualified healthcare providers can perform covered services. Additionally, services are not limited to those provided exclusively in a hospital setting; they may be conducted in various healthcare facilities or even in outpatient situations. Lastly, while some services may require prior authorization depending on the specific circumstances or Medicare Advantage plans, preapproval is not universally required for all services under traditional Medicare. Thus, the comprehensive combination of medical necessity, coverage, and compliance accounts for the central eligibility for Medicare reimbursement.