CMS revises Local Coverage Determinations chapter in Medicare Program Integrity Manual — Here's what you should know

CMS revised a chapter in the Medicare Program Integrity Manual, which details policies and procedures for Medicare Administrative Contractors and provides guidance for stakeholder engagement.

Here's what you should know:

1. The revisions were made to chapter 13, which describes the local coverage determinations process.

2. CMS made changes in response to a provision of the 21st Century Cures Act designed to increase local coverage determination process transparency.

3. The revised manual includes:

  • A step-by-step explanation of the local coverage determination process in accessible language
  • A standardized summary of clinical evidence supporting local coverage determination decisions and the rationale behind MAC coverage determination
  • The option to request an informal meeting with a MAC to discuss potential local coverage determination requests.
  • A new process allowing interested parties in a MAC jurisdiction to request a new local coverage determination.
  • Restructured Contractor Advisory Committee meetings with additional stakeholders involved
  • Open meetings in the MAC jurisdiction to present proposed coverage and reasoning
  • The retirement of proposed policies if not finalized within a year of the original posting date
  • ICD-10-CM and CPT codes removed from local coverage determination in the future
  • MAC responses to public comments linked to the final local coverage determination and stored in the Medicare Coverage Database indefinitely
  • An local coverage determination reconsideration process consistent with the National Coverage Determination reconsideration process

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