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Last Modified: 10/3/2019 Location: FL, PR, USVI Business: Part A, Part B

The LCD reconsideration process

The LCD (local coverage determination) reconsideration process is a mechanism for interested parties to request a revision to an LCD. The process is available only for final effective LCDs. The whole LCD or any provision of the LCD may be reconsidered.
Valid LCD reconsideration request requirements:
1. LCD reconsideration requests will be considered from:
Beneficiaries residing or receiving care in jurisdiction N (Florida, Puerto Rico, and the U.S. Virgin Islands);
Providers doing business in jurisdiction N;
Any interested party doing business in jurisdiction N.
2. First Coast Service Options (First Coast) will only accept reconsideration requests for LCDs published as an effective final LCD. Requests will not be accepted for other documents including:
National coverage determinations (NCDs);
Coverage provisions in interpretive manuals;
Proposed LCDs;
Template LCDs, unless or until they are adopted by First Coast;
Retired LCDs;
Individual claim determinations;
Bulletins, articles, training materials; and
Any instance in which no LCD exists, i.e., requests for development of an LCD.
If modification of the LCD would conflict with an NCD, the request is not valid. To request a revision to an NCD, please refer to the NCD Determination process external link.
For more information on submitting a request for an NCD review, please see the August 7, 2013, Federal Register notice external link. If you need further assistance regarding NCD requests, please email NCDRequest@cms.hhs.gov.
3. LCD reconsideration requests must be submitted in writing, and must identify the language that the requestor wants 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 in your request and must be full text articles.
The level of evidence required for LCD reconsideration is the same as that required for new/revised LCD development as per the Centers for Medicare & Medicaid Services (CMS) internet-only manual (IOM), Publication 100-08, Medicare Program Integrity Manual (PIM), Chapter 13, Section 13.2.
Submit new LCD requests to First Coast via email at medical.policy@fcso.com, or by Faxination to 1-904-361-0422, or by mail to
First Coast Service Options
PO Box 45274
Jacksonville, FL 32232-5274
or
First Coast Service Options
Attn: Medical Policy and Procedures
532 Riverside Ave
Jacksonville, FL 32202-4914
4. Within 60 days of the day the request is received, First Coast will determine if the request is valid or invalid:
Any request for LCD reconsideration that, in the judgment of First Coast, does not meet the criteria described above, is invalid. If the request is invalid, First Coast will respond, in writing, to the requestor explaining why the request was invalid.
If the request is valid, First Coast will notify the requestor of the acceptance of the valid LCD reconsideration request. First Coast will consolidate valid requests, if similar requests are received.
A valid request does not convey that a determination has been made whether or not the item or service will be covered or non-covered under 1862 (a)(1)(A) of the Social Security Act. The response to the requestor that the request is valid is an acknowledgement to the requestor of the receipt of a complete, valid request.
If the request is valid, First Coast will follow the process for LCD reconsiderations detailed in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 13.
Source: CMS IOM Publication 100-08, PIM, Chapter 13, Section 13.3.2
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.