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Medicare Local Medical Review Policies Tool Kit
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Appendices
Hierarchy of laws, policies and guidelines that control Medicare claims
Notice and Comment Period for New LMRPs
Toolkit Home
Part I: LMRP Basics
Part II: Opportunities for Involvement
Part III: The Tools
Appendices
Hierarchy of laws, policies and guidelines that control Medicare claims
National Coverage Determinations (NCD)
These are developed by CMS to describe circumstances and limitations of Medicare coverage for a specific procedure or device. They are published as
CMS Program Instructions. Once published, NCD's operate at a high level of authority. They are binding on all Medicare carriers. Also, if a claim dispute
arises, it may be decided by an Administrative Law Judge. These judges are also bound by NCD's.
Coverage Provisions in Interpretive Manuals
These are coverage instructions published by CMS other than National Coverage Determinations. They are used to further describe circumstances and limitations
of Medicare coverage. Once published, they also become authoritative; they, too, are binding on all Medicare carriers. If a Carrier's current language
is inconsistent with a new CMS determination, the Carrier must change its policy and must publish or provide a link to the policy change on its own website.
Carriers are also required to include these changes in their coverage bulletins as soon as possible.
Articles
Carriers may include in provider bulletins, websites, and educational materials general discussion regarding practice standards, existing National
Coverage Determinations, Program Memoranda issued by CMS, coverage provisions in an interpretive manual, or existing LMRPs.
Individual Claim Determinations
Carriers may review claims on either a prepayment or postpayment basis, regardless of whether any of the above types of policies applies to the service.
Usually, carriers are not permitted to use a system of automatic denial for categories of claims.
When do carriers develop new policy language?
There are circumstances when a carrier must develop or revise an LMRP, when a carrier may develop or revise an LMRP, and when an existing LMRP must
be reviewed.
When MUST a carrier develop or revise an LMRP?
A carrier is obligated to develop an LMRP when it wishes to introduce a new circumstance of automated review. In other words, when a carrier has taken
the position that a service is never covered under certain, identifiable circumstances and it wishes to establish an automatic denial process (usually
by way of a computer program that recognizes the claim), it must develop LMRP language to set forth the coverage limitation and terms of automatic denial.
A new LMRP is not necessary if a National Coverage Determination or interpretive manual supports the automatic review.
When MAY a carrier develop or revise an LMRP?
A carrier may develop or revise an LMRP when it has identified a widespread problem that demonstrates a significant risk to the Medicare trust funds.
A carrier may develop or revise an LMRP when it has determined that policy language is needed to assure beneficiary access to care.
A carrier may develop or revise an LMRP when frequent denials are issued or anticipated.
A carrier may develop or revise an LMRP when it has assumed the LMRP development workload of another carrier and is undertaking an initiative to create
uniform LMRPs across its multiple jurisdictions
When MUST a carrier review an existing LMRP?
As of October 2001, all carriers must review all LMRPs annually to ensure that they are consistent with National Coverage Determinations, coverage
provisions in interpretive manuals, national payment policies, and national coding policies.
In addition, a carrier must review an existing LMRP within 90 days of the publication of a new or revised National Coverage Determination, a new or
revised coverage provision in an interpretive manual, or a change to national payment policy.
A carrier must also review an existing LMRP within 120 days of publication of an update to the ICD-9 or HCPCS coding systems.
Notice and Comment Period for New LMRPs
strong>What are the notice and comment requirements?
CMS recently promulgated requirements that carriers post their draft LMRP's and dates of meetings, including provision of a forum for discussion of
coverage terms, on the internet.
Program Memorandum, Transmittal AB-00-116, dated November 24, 2000 provides that carriers must allow for the submission of information from the public
to assure that the development of LMRPs occurs through a public and open process.
Carriers must provide open meetings for the purpose of discussion of draft LMRPs and must allow interested parties to submit scientific, evidence-based
information, professional consensus opinions, or any other relevant information.
If time or space are insufficient for all information to be presented in open meeting, then comments provided to the CMD in writing, including by e-mail,
must also be given full and equal consideration.
The comment period must be a minimum of 45 days.
Carriers also have web-based requirements for notice and comment
A draft LMRP must be posted on the carrier's web site, including the start and stop date of the comment period and both email and postal addresses
for comments.
The carrier's web site must also contain an "LMRP status page," setting forth the draft LMRP title, date of release for comment, email and postal address
for comments, end date for comment period, current status, actual date of release of final LMRP, and web site link to final LMRP.
The carrier's web site must provide a summary of comments received concerning the draft LMRP with the carrier's response. The comment/response document
needs to be posted on the web for 3-6 months.
The carrier must also complete a draft LMRP form on www.draftLMRP.net within 2 business days of the draft being posted to the carrier's site.
After all comments have been considered and all revisions made as needed, the carrier must provide a minimum notice period of 45 calendar days on the
final LMRP.
Final LMRP Publication Requirements
Carriers must make final LMRPs public by special bulletin, update to a provider manual, or inclusion in a newsletter.
Carriers must post all final LMRPs on their web site.
Carriers must update www.lmrp.net when they issue a new or revised LMRP.
Who is expected to comment?
The carrier must solicit comments and recommendations on the draft LMRP from at least the following sources:
Appropriate groups of health professionals and provider organizations that may be affected by the LMRP;
- Representatives of specialty societies;
- Other intermediaries/carriers;
- Quality Improvement Organizations within the region;
- Other Carrier Medical Directors within the region;
- General public;
- Carriers should make an effort to ensure that providers with a history of billing for the service are informed of the proposed LMRP and have an opportunity
to comment
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