Journey to LCD coverage
Click each step below to better understand how LCDs can work for you.
| Step 1 - Understanding LCDs |
Tips |
|---|---|
| How do I check to see if a service is covered? |
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| How do LCDs relate to processing claims? |
If there is an applicable LCD for an item/service, follow the guidelines in the LCD and companion Local Coverage Article when submitting claims If no applicable LCD but there is an NCD, claims process according to the NCD If no applicable LCD, local coverage article, NCD, or CMS manual instructions; reasonable and necessary guidelines still apply and services are processed for consideration. If a claim denies, you have the right to request a claim redetermination (appeal) |
| Why are LCDs developed or retired? |
LCDs are developed to convey under what circumstances an item/service is considered to be reasonable and necessary Visit our LCD development process to learn more about how and why LCDs are developed Visit our LCD retirement process to understand why LCDs may be retired. |
| Step 2 - Development process |
Tips |
|---|---|
| How can I be involved in the LCD development process? |
Volunteer to become a CAC member and be involved in evidentiary review CAC meetings If you don't want to be a CAC member, you can still participate in any open meeting and/or provide written comments on a proposed LCD Keep us informed about a new drug, device, test, updated costs or indications using our submission of new drug information protocol |
| What if I want an LCD revised or a new LCD developed? |
An LCD is not written to convey an item/service is covered, but can set coverage limitations or establish non-coverage of an item/service If there is no active LCD for an item/service and you would like one developed, submit a request for a new LCD View New LCD request process flowchart If there is an active LCD that you would like revised, submit an LCD reconsideration request View LCD reconsideration request process flowchart All LCDs must be based on evidence. Please read our Evidence-based Health Policy: Literature Review Methodology for Local Coverage Determinations article. |
| I received confirmation my new LCD request or LCD reconsideration request is valid. Now what? |
New LCD request topics and valid LCD reconsideration requests are waitlisted and undergo our internal prioritization process At MAC discretion, a new LCD topic may go to an evidentiary review Contractor Advisory Committee (CAC) meeting New and revised proposed LCDs undergo a 45-day public comment period and an open meeting MACs are to finalize or retire all proposed LCDs within a rolling year of publication date of the proposed LCD on CMS' Medicare coverage database (MCD) (365 days) |
| Step 3 - Find available resources |
Tips |
|---|---|
| How do I find information about claims or appeals? |
Visit our claims page for information on claim billing, coding, NCCI, MUE, submission, status, issues, rejections, or denials Electronic billers can visit the Electronic billing - EDI page and SPOT portal Visit our Appeals page for information on submitting a claim redetermination (appeal) or status of an appeal Contact us if you have any questions |
| What educational opportunities are available? |
Increase your knowledge of the Medicare program by participating in live and on-demand education by visiting our Learning center General Frequently asked questions (FAQs) Visit the LCDs/Medical affairs page Stay informed of LCD and other updates by subscribing to our email list |