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CMS PROPOSES APPEALS
PROCESS FOR MEDICARE COVERAGE
DECISIONS
August 21, 2002
The Centers for Medicare & Medicaid Services (CMS) proposed a rule today that would
establish a process for beneficiaries to appeal local or national Medicare coverage
determinations. The proposed rule provides for independent review of these coverage
policies.
Under the proposal, appeals of local coverage determinations (LCDs) would be reviewed
initially by an administrative law judge (ALJ). Appeals from national coverage
determinations (NCDs) and from ALJ decisions on LCDs would be reviewed by the Health and
Human Services Departmental Appeals Board. The board's decisions could be
appealed to federal court.
The proposed rule is a first step toward formal implementation of several provisions of
Section 522 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act
(BIPA) of 2000.
Beneficiaries already have the right to appeal individual claims denials when they
believe a covered item or service was denied improperly. The proposed rule would
give them an additional avenue to challenge the underlying coverage policy. The new
appeals process would ensure that complaints are reviewed in a predictable, uniform
manner. In addition, decisions in these appeals may have implications for future Medicare
coverage of the item or service for all Medicare beneficiaries, not just the individual
who filed the appeal.
CMS has already implemented a process for any interested party to follow when seeking a
change in a national coverage determination. More recently, it has instructed the private
insurers that process Medicare claims for CMS to establish and publicize a process, to
become effective October 1, for certain interested parties to use to seek reconsideration
of a local medical review policy. This is in addition to the process outlined in the
proposed rule.
"This proposed rule will build on the policies CMS has already put into place to
provide beneficiaries with the opportunity to seek review of CMS coverage policies,"
says CMS Administrator Tom Scully. "Unfortunately, when Congress enacted the BIPA
provisions addressing appeals, it did not provide additional funding to the Medicare
program for the associated costs. Consequently, this has caused some delays in
implementing this new process because CMS has had to reallocate funds from other high
priority and Congressionally-mandated activities to underwrite the expanded appeals
process."
NCDs are made by CMS and must be followed by all contractors that process and pay Medicare
claims. LCDs are made by the contractors and apply only in the areas served by the
individual contractor.
The proposed rule will be published in the Aug. 22 Federal Register. CMS will accept
public comments on the proposed rule until Oct. 21, and plans to publish a final rule as
soon as practicable after the public comment period is completed.
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Note: The existing policy for seeking reconsideration of NCDs can be found on the CMS
Website at www.cms.hhs.gov/coverage/8a1.asp. The policy
for seeking reconsideration of LMRPs can be found at www.cms.gov/manuals/108_pim/pim83c13.asp#Sect11.
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