What is the purpose of Coverage Determination in CMS?

• A. To decide whether a service or item is covered under specific circumstances and for a particular patient.
• B. To set the list price of drugs.
• C. To authorize international referrals.
• D. To audit provider billing accuracy.

Answer: (A)

Coverage determination focuses on whether a service or item is covered by CMS for a specific patient in a particular clinical situation. It weighs policy rules, medical necessity, and the applicable national or local coverage determinations to decide if CMS will pay for the service and under what conditions. It also clarifies any patient eligibility factors and what costs the patient may incur. This is distinct from actions like setting drug prices, authorizing international referrals, or auditing billing accuracy, which are separate CMS processes.