In addition to creating the term “Local Coverage Determination” (LCD), section 1869(f) of the Social Security Act creates an appeals process for an “aggrieved party” to challenge LCDs/LCD provisions that are in effect at the time of the challenge. “Aggrieved party” is defined in regulation as a Medicare beneficiary, or the estate of a Medicare beneficiary, who is entitled to benefits under Part A, enrolled under Part B, or both (including an individual enrolled in fee-for-service Medicare, in a Medicare Advantage plan (MA), or in another Medicare managed care plan), and is in need of coverage for an item or service that would be denied by an LCD, as documented by the beneficiary’s treating physician, regardless of whether the service has been received. An aggrieved party has obtained documentation of the need by the beneficiary’s treating physician. For more information on the LCD Challenge process please see https://www.medicare.gov/claims-appeals/local-coverage-determinations-lcd-challenge.
Full Answer
What is a Local Coverage Determination (LCD) challenge?
Local Coverage Determinations (LCD) challenge. What’s a "Local Coverage Determination" (LCD)? LCDs are decisions made by a Medicare Administrative Contractor (MAC) whether to cover a particular item or service in a MAC’s jurisdiction (region) in accordance with section 1862(a)(1)(A) of the Social Security Act.
Who are the administrative contractors for Medicare?
Medicare Administrative Contractors Since Medicare’s inception in 1966, private health care insurers have processed medical claims for Medicare beneficiaries. Originally these entities were known as Part A Fiscal Intermediaries (FI) and Part B carriers.
Can You challenge a Medicaid LCD?
You can challenge an LCD if both of these apply: Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services. , or both.
What is an LCD in Medicare?
LCDs are decisions made by a Medicare Administrative Contractor (MAC) whether to cover a particular item or service in a MAC’s jurisdiction (region) in accordance with section 1862 (a) (1) (A) of the Social Security Act. MACs are Medicare contractors that develop LCDs and process Medicare claims.
Can you appeal an LCD denial?
In addition to creating the term “Local Coverage Determination” (LCD), section 1869(f) of the Social Security Act creates an appeals process for an “aggrieved party” to challenge LCDs/LCD provisions that are in effect at the time of the challenge.
Can physicians and collectors request an LCD and revise an LCD?
3. The LCD reconsideration process is a mechanism by which a beneficiary or stakeholder (including a medical professional society or physician) in NGS jurisdiction can request a revision to an LCD.
What is an LCD denial?
It also may include a denial notice that explains that an LCD doesn't cover a certain item or service. This is because that item or service isn't considered reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the function of a malformed part of the body.
What are LCD guidelines?
An LCD is a determination by a Medicare Administrative Contractor (MAC) whether to cover a particular service on a. Coverage criteria is defined within each LCD , including: lists of HCPCS codes, codes for which the service is covered or considered not reasonable and necessary.
What is a Medicare administrative contractor?
A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries.
What jurisdiction is covered by LCDs?
The coverage policy created by an LCD is applicable only in States within a contractor's jurisdiction. CMS's Medicare Program Integrity Manual instructs contractors on how to develop LCDs.
What are the possible solutions to a denied claim?
A majority of denied claims are administrative errors and once corrected you can resubmit them to the insurance payer. Denied claims with a clinical reason may require you to submit an appeal letter: always send this by certified or registered mail.
How do you handle Medicare denials?
File your appeal within 120 days of receiving the Medicare Summary Notice (MSN) that lists the denied claim. Circle the item on your MSN that you are appealing and clearly explain why you think Medicare's decision is wrong. You can write on the MSN or attach a separate page.
How do I fix Medicare denials?
If Your Medicare Carrier Denies a Claim...Examine the Explanation of Benefits (EOB) from the carrier, which should include the reason for a claims denial. ... Have a standardized letter handy asking the insurance carrier to reconsider your claim. ... Consider invoking your right to an appeal an adverse claims decision.
Do Medicare Advantage plans have to follow LCDs?
Medicare Advantage plans are required to follow all Medicare laws and coverage policies, including LCDs (Local Coverage Decisions - coverage policies set by Medicare Fee-for-Service Contractors in your geographic area), when determining coverage for a particular service.
How do you find the local coverage determination for the local Medicare Administrative Contractor?
How to locate your Medicare contractor's LCDs. ... Once the Medicare Coverage Database (MCD) ... documents” in the “quick search” section. ... Select your area from the. ... In the “select one or both” section, enter. ... Click the “search by type” button.Your search results will show if your Medicare. ... To view the LCD, click on the LCD number.More items...
Does NCD supersede LCD?
NCDs supersede LCDs, but LCDs expand on coverage policies for each jurisdiction, and these coverage policies may vary, including information regarding appropriate coding, credentialing, diagnostic testing, and treatment.
General Information
CPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Article Guidance
The requirements in this article are based on instructions found in CMS Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.3.1, 13.3.2 and 13.3.3.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
What is LCD in Medicare?
An LCD is a determination by a Medicare Administrative Contractor (MAC) whether to cover a particular service on a MAC-wide, basis. Coverage criteria is defined within each LCD, including: lists of HCPCS codes, ICD-10 codes for which the service is covered or considered not reasonable and necessary. View published Active LCDs on our website and ...
What is NCD in medical terminology?
A new or revised National Coverage Determination (NCD) A new or revised coverage provision in an interpretive manual; or. A change to national payment policy. The MCD will notify contractors of each LCD that is affected by HCPCS or diagnosis code updates.