CMS Coverage Connector

CMS Coverage Connector#

The CMS Coverage Connector gives Claude access to Medicare Part B coverage policies from the CMS Coverage Database, including National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).

What You Can Do#

With this connector, Claude can help you:

  • Search Medicare Part B coverage policies

  • Find National and Local Coverage Determinations

  • Review billing and coding guidance articles

  • Check coverage criteria for procedures and services

  • Track recent policy changes

  • Identify Medicare Administrative Contractors by state

Data Source: CMS Coverage Database API v1

MCP Endpoint: https://mcp.deepsense.ai/cms_coverage/mcp

Important: Covers Medicare Part B only (medical services, not prescription drugs)

Getting Started#

Adding the Connector to Claude#

  1. Open Claude’s Connector Settings

    • In Claude Desktop, select your profile icon in the bottom left

    • Navigate to Settings → Connectors

  2. Find the CMS Coverage Connector

    • Browse the available connectors catalogue

    • Search for “CMS Coverage” or find it under Healthcare connectors

  3. Enable the Connector

    • Click on the CMS Coverage Connector

    • Click “Enable” or “Add Connector”

    • The connector will be activated immediately

    • No authentication required - the connector works immediately after enabling

  4. Verify the Connection

    • Ask Claude: “Does Medicare cover PET scans?”

    • Claude should use the CMS Coverage connector to search policies

What Medicare Part B Covers#

This connector includes:

  • Medical services (physician visits, outpatient care)

  • Injectable and infused drugs given in medical settings

  • Durable Medical Equipment (DME)

  • Laboratory tests and diagnostics

  • Home health services

  • Preventive screenings

NOT included in this connector:

  • Part D: Oral prescription drugs

  • Part A: Inpatient hospital services

  • Part C: Medicare Advantage plans

  • Medicaid or private insurance policies

Available Tools#

National Coverage Tools#

1. Search National Coverage#

What it does: Unified search for all national coverage documents - NCDs, NCAs, CALs, MEDCAC meetings, and technology assessments.

Use it for:

  • Finding national coverage policies and analyses

  • Checking coverage for new technologies

  • Understanding Medicare’s position on treatments

  • Researching coverage decision rationale

  • Tracking MEDCAC meetings and technology assessments

Example queries:

  • “Does Medicare cover PET scans?” (searches NCDs)

  • “Find NCAs for cardiac devices” (searches coverage analyses)

  • “Search for MEDCAC meetings on genetic testing”

  • “What technology assessments exist for immunotherapy?”

What Claude will do:

  1. Search national documents by keyword

  2. Filter by document type (NCD, NCA, CAL, MEDCAC, technology assessment)

  3. Return matching policies with:

    • Document numbers and titles

    • Effective dates

    • Links to full documents

    • Status and decision information

  4. Support searching across all document types or specific types

Pagination:

This tool supports pagination for large result sets. When there are more results than the limit, use the next_page_token from the response to fetch the next page.

Pagination parameters:

  • limit (1-200, default 20): Number of results per page

  • page_token: Token from previous response’s next_page_token field

  • sort_by: Sort field - options: ‘title’, ‘last_updated_sort’, ‘document_id’

  • sort_order: ‘asc’ or ‘desc’ (default: ‘desc’)

  • count_total: Set to true to include total count (may slow down query)

Response includes:

  • count: Number of items in current page

  • total: Total matching documents (only if count_total=true)

  • next_page_token: Token for next page (null if no more results)

  • items: Array of matching documents

Example pagination workflow:

  1. First request: limit=50, count_total=true

  2. Response: count=50, total=237, next_page_token="xyz123"

  3. Next request: limit=50, page_token="xyz123"

  4. Continue until next_page_token is null

2. Get Coverage Document#

What it does: Retrieves complete information for a specific coverage document by ID and type.

Use it for:

  • Reading full policy text

  • Understanding coverage criteria

  • Checking indications and limitations

  • Finding coding requirements

  • Accessing complete NCA/CAL details

Example queries:

  • “Show me details for NCD 220.6”

  • “Get the full text of NCA 123”

  • “What are the coverage criteria in CAL 456?”

What Claude will do:

  1. Retrieve the complete document (NCD, NCA, or CAL)

  2. Present coverage criteria and limitations

  3. Show coding information and requirements

  4. Provide effective dates and transmittals

  5. Include decision rationale (for NCAs/CALs)

3. Batch Get NCDs#

What it does: Retrieves multiple National Coverage Determinations in a single request (up to 20 NCDs).

Use it for:

  • Efficiently fetching details for multiple policies

  • Comparing coverage across related conditions

  • Building comprehensive coverage summaries

  • Reducing API calls when analyzing multiple NCDs

Example queries:

  • “Get details for NCDs 220.6, 220.13, and 220.15”

  • “Show me all diabetes-related NCDs” (after finding IDs from search)

  • “Compare coverage for these cardiac NCDs: 20.7, 20.8, 20.9”

What Claude will do:

  1. Retrieve up to 20 NCDs in one call

  2. Return complete details for each NCD:

    • Full policy text

    • Coverage criteria

    • Coding requirements

    • Effective dates

  3. Handle partial success (some NCDs found, others not)

  4. Provide error details for any failed retrievals

Local Coverage Tools#

4. Search Local Coverage#

What it does: Unified search for all local coverage documents - Final LCDs, Proposed LCDs, and billing Articles.

Use it for:

  • Finding local/regional coverage policies

  • Checking state-specific requirements

  • Understanding local medical necessity criteria

  • Accessing billing and coding guidance

  • Tracking proposed policy changes

Example queries:

  • “Search LCDs for physical therapy in California” (searches final LCDs)

  • “Find proposed LCDs for genetic testing” (searches proposed)

  • “What ICD-10 codes are covered for wound care in Texas?” (searches articles)

  • “Find billing articles for LCD L12345”

What Claude will do:

  1. Search local documents by keyword

  2. Filter by document type (LCD, Proposed LCD, Article)

  3. Filter by MAC/contractor or state if specified

  4. Return matching documents with:

    • Document IDs and titles

    • MAC information

    • Effective dates

    • Comment periods (for proposed)

    • Covered codes (for articles)

Pagination:

This tool supports pagination for large result sets. When there are more results than the limit, use the next_page_token from the response to fetch the next page.

Pagination parameters:

  • limit (1-200, default 20): Number of results per page

  • page_token: Token from previous response’s next_page_token field

  • sort_by: Sort field - options: ‘title’, ‘updated_on_sort’, ‘effective_date’, ‘document_id’

  • sort_order: ‘asc’ or ‘desc’ (default: ‘desc’)

  • count_total: Set to true to include total count (may slow down query)

Response includes:

  • count: Number of items in current page

  • total: Total matching documents (only if count_total=true)

  • next_page_token: Token for next page (null if no more results)

  • items: Array of matching documents

Example pagination workflow:

  1. First request: limit=50, count_total=true

  2. Response: count=50, total=158, next_page_token="abc456"

  3. Next request: limit=50, page_token="abc456"

  4. Continue until next_page_token is null

Policy Tracking Tools#

5. What’s New#

What it does: Tracks recent coverage changes - both national and local policies.

Use it for:

  • Monitoring policy changes (national or local)

  • Staying current on coverage updates

  • Tracking new technologies and treatments

  • Planning for policy implementations

  • Identifying policy revisions in your region

Example queries:

  • “What national coverage policies changed recently?” (national scope)

  • “Show me new LCDs in California from the past 30 days” (local scope)

  • “Have there been recent updates to genetic testing policies?” (can search both)

  • “Track coverage changes in Texas over the last 60 days”

What Claude will do:

  1. Search for recent changes by scope:

    • National: NCDs, NCAs, CALs, MEDCAC, technology assessments

    • Local: LCDs, Proposed LCDs, Articles (by contractor/region)

  2. Apply timeframe filters:

    • National: Days back (1-120, default 30)

    • Local: Date range filtering

  3. Return new and revised documents with:

    • Effective dates

    • Change descriptions

    • Document types and IDs

  4. Filter by contractor for local changes

Pagination:

This tool supports pagination for large result sets. When there are more results than the limit, use the next_page_token from the response to fetch the next page.

Pagination parameters:

  • limit (1-200, default 20): Number of results per page

  • page_token: Token from previous response’s next_page_token field

  • sort_by: Sort field - options differ by scope:

    • National: ‘title’, ‘last_updated_sort’, ‘document_type’, ‘document_id’

    • Local: ‘title’, ‘updated_on_sort’, ‘effective_date’, ‘document_id’

  • sort_order: ‘asc’ or ‘desc’ (default: ‘desc’)

  • count_total: Set to true to include total count (may slow down query)

Response includes:

  • count: Number of items in current page

  • total: Total matching documents (only if count_total=true)

  • next_page_token: Token for next page (null if no more results)

  • items: Array of matching documents

Example pagination workflow:

  1. First request: scope='national', limit=30, count_total=true

  2. Response: count=30, total=85, next_page_token="def789"

  3. Next request: scope='national', limit=30, page_token="def789"

  4. Continue until next_page_token is null

Support Tools#

6. SAD Exclusion List#

What it does: Searches the Self-Administered Drug (SAD) Exclusion List - oral drugs NOT covered under Medicare Part B (they’re covered under Part D instead).

Use it for:

  • Verifying if an oral drug is Part B covered

  • Understanding why a drug claim was denied under Part B

  • Determining correct benefit category (Part B vs Part D)

  • Guiding patients to Part D coverage for oral medications

  • Finding excluded drugs by HCPCS code or name

Important: Oral self-administered drugs are excluded from Part B and should be billed under Part D prescription drug plans.

Search parameters:

  • hcpcs_code: Filter by specific HCPCS code (e.g., ‘J0135’)

  • keyword: Search drug names and article text

  • date_option: ‘current’, ‘effect’, or ‘range’ (default: ‘current’)

  • start_date, end_date: Date range in YYYYMMDD format (for date_option=‘range’)

Pagination parameters:

  • limit (1-200, default 20): Results per page

  • page_token: Token for next page

  • sort_by: Options: ‘title’, ‘code_id_sort’, ‘drug_brand_name’, ‘updated_on_sort’, ‘effective_date’

  • sort_order: ‘asc’ or ‘desc’ (default: ‘desc’)

  • count_total: Include total count

Example queries:

  • “Is imatinib excluded from Part B coverage?” (search by keyword)

  • “Check HCPCS code J9999 in SAD exclusion list” (by code)

  • “Show me all oral anticancer drugs excluded from Part B” (by keyword)

  • “Why was my oral chemotherapy claim denied under Part B?” (educational)

What Claude will do:

  1. Search the SAD exclusion list by HCPCS code or keyword

  2. Return matching excluded drugs with:

    • HCPCS codes

    • Drug brand and generic names

    • Exclusion effective dates

    • Article references

  3. Explain that excluded drugs must be billed under Part D

  4. Support pagination for large result sets

  5. Allow sorting by various fields

Response includes:

  • count: Number of items in current page

  • total: Total matching drugs (only if count_total=true)

  • next_page_token: Token for next page (null if no more results)

  • items: Array of excluded drug entries

7. Get Contractors#

What it does: Finds Medicare Administrative Contractors (MACs) by state or contractor ID.

Use it for:

  • Identifying which MAC covers your state

  • Finding MAC contact information

  • Determining applicable local policies

  • Understanding jurisdiction coverage

Example queries:

  • “Which Medicare contractor handles California?”

  • “Find the MAC for Texas”

  • “Who processes Medicare claims in New York?”

  • “Show me all MACs and their jurisdictions”

What Claude will do:

  1. Identify the MAC for the specified state or show all contractors

  2. Provide contractor name and ID

  3. Show jurisdiction information

  4. List states/regions covered by each MAC

Usage Examples#

Example 1: Checking Coverage for a Procedure#

You: “Does Medicare Part B cover genetic testing for breast cancer?”

Claude will:

  1. Use Search National Coverage with document_type=‘ncd’ to check for national policies

  2. If found, use Get Coverage Document to show full coverage criteria

  3. If no NCD, use Search Local Coverage with document_type=‘lcd’ to check for local policies

  4. Use Search Local Coverage with document_type=‘article’ to find covered diagnosis codes

  5. Explain coverage criteria and any limitations

Example 2: Prior Authorization Preparation#

You: “I need to prepare a prior authorization for a PET scan in California. What documentation does Medicare require?”

Claude will:

  1. Use Search National Coverage with document_type=‘ncd’ to find the PET scan policy

  2. Use Get Coverage Document to retrieve full coverage criteria

  3. Use Get Contractors to identify California’s MAC

  4. Use Search Local Coverage with document_type=‘article’ and contractor filter for billing guidance

  5. List required documentation, covered indications, and ICD-10 codes

Example 4: Paginating Through Large Result Sets#

You: “Find all NCDs related to diabetes and show me the first 10, sorted by most recently updated”

Claude will:

  1. Use Search National Coverage with:

    • keyword=‘diabetes’

    • document_type=‘ncd’

    • limit=10

    • sort_by=‘last_updated_sort’

    • sort_order=‘desc’

    • count_total=true

  2. Return first 10 results with total count (e.g., “Showing 10 of 47 results”)

  3. Provide next_page_token in response

  4. If you ask for more: Use the page_token to fetch next 10

  5. Continue pagination until all results retrieved or user stops

Example 5: Checking Drug Coverage Under Part B#

You: “Is oral imatinib (Gleevec) covered under Medicare Part B?”

Claude will:

  1. Use SAD Exclusion List with keyword=‘imatinib’

  2. Find imatinib in the exclusion list

  3. Explain:

    • Imatinib is a self-administered oral drug

    • It’s EXCLUDED from Part B coverage

    • It’s covered under Part D (prescription drug plans)

    • Part B only covers injectable/infused versions administered by providers

  4. Provide HCPCS codes for the excluded formulations

  5. Guide patient to check their Part D formulary

Example 6: Staying Current on Policy Changes#

You: “Have there been any Medicare coverage changes in the last month that affect my practice in Texas?”

Claude will:

  1. Use What’s New with scope=‘national’ to check recent NCD/NCA/CAL changes

  2. Use What’s New with scope=‘local’ filtered by Texas contractor to check LCD updates

  3. Summarize new and revised policies

  4. Highlight policies relevant to your specialty

  5. Note effective dates for upcoming changes

Need Help?#

For issues or questions about the CMS Coverage Connector, see our Troubleshooting Guide.

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