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Policies - Overview & Reconsideration Process National Coverage Determinations and, Local Coverage Determinations provide reasonable and necessary indications and limitations of Medicare coverage. National Coverage Determination Overview (NCDs) A NCD sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Medicare contractors are required to follow NCDs. If a NCD does not specifically exclude/limit an indication or circumstance, or if the item or service is not mentioned at all in a NCD or in a Medicare manual, it is up to the Medicare contractor to make the coverage decision (see Local Coverage Determinations below). Prior to a NCD taking effect, CMS must first issue a Manual Transmittal, CMS ruling, or Federal Register Notice giving specific directions to our claims-processing contractors. The issuance, which includes an effective date and implementation date, is the NCD. If appropriate, the Agency must also change billing and claims processing systems and issue related instructions to allow for payment. The NCD will be published in the Medicare National Coverage Determinations Manual. A NCD becomes effective as of the date listed in the transmittal that announces the manual revision. Local Coverage Determination Overview (LCDs) A LCD, as established by Section 522 of the Benefits Improvement and Protection Act, is a decision by a fiscal intermediary or contractor whether to cover a particular service on an intermediary-wide or contractor-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (i.e., a determination as to whether the service is reasonable and necessary). In the absence of national policy, Local Coverage Determinations are developed to specify criteria that describe whether the item/service is covered and under what clinical circumstances the item/service is considered to be reasonable and necessary. Medicare Contractors are responsible for determining local coverage based on the advice and input of medical and specialty societies, and review of current medical practice, clinical data and research studies. Updates on new and revised LCDs are published in each issue of Medicare B Resource. Providers may call Provider Services for a copy of a new, revised or retired policy. Maine: 877/567-3129 Local Coverage Determination Reconsideration Process The Local Coverage Determination (LCD)Reconsideration Process is a mechanism by which interested parties can request a revision to an LCD. Interested parties are:
Scope The LCD Reconsideration Process is available only for final LCDs. The whole LCD or any part of the LCD may be reconsidered, i.e., Benefit Category Provisions, Utilization Guidelines, Covered ICD-9 codes, etc. Valid LCD Reconsideration Request Requirements Reconsideration requests are only accepted for LCDs published in final form. Requests will not be accepted for the following:
Requests must be submitted in writing and must identify the language to be added to or deleted from an LCD. Requests must include a justification supported by new evidence, which may materially affect the LCD's content or basis. Copies of published evidence must be included. The level of evidence required for LCD reconsideration is the same as that required for new/revised LCD development. (Medicare Program Integrity Manual (100-08), Chapter 13, Section 7.1) Any request for LCD reconsideration that, in the judgment of NHIC, Corp. does not meet these criteria is invalid. If modification of the LCD would conflict with an NCD, the request would not be valid. For the NCD Reconsideration Process, please visit: http://www.cms.hhs.gov/DeterminationProcess/. Submit Requests Submit Requests to: FAX: (781) 741-3211 E-MAIL: craig.haug@eds.com Process Valid or Invalid Request
If the decision is to revise the LCD, the contractor will follow the normal process for LCD development. 02/07/2008 |
