Coverage/Medical Review

Policy

Medicare policies are used by the contractor to apply Medicare coverage guidelines. These policies are generally divided into National Coverage Determinations (NCDs), coverage provisions in interpretive manuals, and Local Coverage Determinations (LCDs).

NCDs are developed by the Centers for Medicare & Medicaid Services (CMS) to describe the circumstances for Medicare coverage nationwide for a specific medical service procedure or device. For more information on these provisions, please visit the CMS Web site.

Coverage provisions in interpretive manuals are instructions that are used to further define when and under what circumstances services may be covered (or not covered). For more information on these provisions, please visit the CMS Web site.

LCDs are decisions by a contractor whether to cover a particular service on a contractor wide basis in accordance with Section 1862 (a)(1)(A) of the Social Security Act (i.e. reasonable and necessary). For more information on LCDs, visit our LCD Homepage.

Medical Review

The Medical Review Program is designed to promote a structured approach in the interpretation and implementation of Medicare policies. CMS makes it a priority to automate this process; however it may require the evaluation of medical records to determine the medical necessity of Medicare claims. The goal of the contractor’s MR Program is to participate in reducing the contractor’s claims payment error rate (CERT) by identifying, through analysis of data and evaluation of other information, program vulnerabilities concerning coverage and coding made by individual providers and by taking the necessary action to prevent and address the identified vulnerabilities.

Page last updated:July 31, 2009

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