Hidden Risks: Medicare Reporting Requirements for Internal Coverage Criteria
Presentation to the Association for Community Affiliated Plans (“ACAP”)
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May 01, 2026
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Beginning in April of 2026, all Medicare Advantage Organizations (“MAO”) will be required to submit detailed information on internal coverage criteria (“ICC”) used for prior authorization and medical necessity decisions for Part B and C services. The initial submission is due April 30, 2026 and subsequent submissions are due February 28 of each year thereafter. CMS seeks to clarify and define ICCs that MAO use when coverage standards are not available through Local Coverage Determination, National Coverage Determination, or Medicare Statues. CMS sees the independent, opaque and non-standardized development of ICCs within MAOs as one of the reasons for high inappropriate denial rates and significant variation in denial of coverage across MAOs.
The 2026 mandatory ICC reporting represents the first review of all ICCs by CMS and is designed to increase transparency across all MAOs. What isn’t obvious and is a risk to MAOs is that CMS defines ICCs broadly and includes criteria developed by third party delegates such as InterQual, Milliman and eviCore. Most MAOs have not considered these criteria as their own internal coverage criteria and most do not have processes in place to ensure that the ICC they create are compliant.
Why It Matters
This regulation presents an opportunity to re-exam the prior authorization process across the MAO, improve compliance internally within the MAO and ensure that all delegated entities are also compliant with internal coverage criteria.
We will explore:
- What plans will need to do to be ready for the public submission of data.
- What structures plans will need to develop to ensure consistent evaluation, analysis and compliance for all ICC- including delegated entities.
- What transparency could mean to MAOs and how CMS might use transparency to enforce standardization.
- How the ICC data could lead to targeted audits, and how plans need to prepare.
Related Insights
Related Information
Published
May 01, 2026
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