Providers and their staff typically need to know where to find guidance regarding coding, coverage, medical necessity, limitations, documentation requirements, and more. Often this guidance differs based on the third-party payer. However, in many cases, this guidance is free and readily accessible online. 

 

Medicare 

Medicare is a national program, but it is administered locally by Medicare Administrative Contractors (MACs). There are seven Part B MACs in the United States. Some of the Part B MACs have large jurisdictions, including 13 states, and some have small jurisdictions, including only two states.  

 

Providers and staff must know which Part B MAC has jurisdiction over their state. When navigating to Part B MAC's website, providers can find a list of policies. Part B MAC's Local Coverage Determinations (LCDs) can be found here. LCDs guide coverage, medical necessity, limitations, documentation requirements, and more. In many cases, an LCD is accompanied by a Local Coverage Article (LCA) that offers guidance regarding coding. Part B MACs choose to issue LCDs for certain services. Different Part B MACs issue LCDs for additional assistance. For example, one Part B MAC may have an LCD for ulcer debridement, while another may not. Perhaps even more important to understand is that two different Part B MACs' LCDs may have additional guidance. This is why it is so essential for providers to look for advice from their own Part B MAC rather than from national forums in many cases. Furthermore, providers in one Part B MAC's jurisdiction may not find the correct guidance if speaking to a colleague about coverage guidelines if that colleague practices in a state that falls under the jurisdiction of a different Part B MAC. A provider in Pennsylvania may be subject to guidelines other than a provider in New York State for certain services. 

 

The Part B MAC with jurisdiction over Pennsylvania is Novitas Solutions. It is good practice for providers to review the list of LCDs issued by their Part B MAC. Pennsylvania providers can find a list of active Novitas LCDs here:  https://www.novitas-solutions.com/webcenter/portal/MedicareJL/LCD?type=active

 

It is also recommended that providers and their staff subscribe to the e-mail listserv of the Part B MAC, which has jurisdiction over their state. Updates to these coverage determinations are shared via these listservs. Pennsylvania providers can and staff can subscribe to the Novitas e-mail listserv here:  https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00007968

 

When providing Part B services to Medicare beneficiaries, guidance regarding coding, coverage, medical necessity, and documentation requirements comes from the Part B MAC, not from Medicare. Most of the time, the question, "What are the Medicare guidelines for ________" is the wrong question, and instead that question should be, "What are my MAC's guidelines for ________?" Most of the time, the question, "How frequently does Medicare allow payment for ________" is the wrong question, and instead that question should be, "How frequently does my MAC allow payment for ________?" Most of the time, the question, "Does Medicare cover ________" is the wrong question, and instead that question should be, "Does my MAC cover ________?"   

 

 

DMEMACs 

Just as the Part B MACs issue LCDs, the DMEMACs do the same. There are only two DMEMACs in the United States, and Pennsylvania falls under the jurisdiction of Noridian DME MAC. It is recommended that providers who prescribe and supply DME review the list of LCDs issued by their DME MAC. Pennsylvania providers can find a list of active Noridian DME LCDs here:    https://www.cms.gov/medicare-coverage-database/reports/local-coverage-final-lcds-contractor-report.aspx?contractorName=5&contractorNumber=389%7c1&lcdStatus=all

 

Furthermore, it is recommended that providers and their staff who are involved with prescribing and supplying DME subscribe to the e-mail listserv of the DME MAC, which has jurisdiction over their state. Updates to these coverage determinations are shared via these listservs. Pennsylvania providers can and staff can subscribe to the Noridian DME MAC e-mail listserv here:   

https://naslists.noridian.com/list/area.html;jsessionid=705DA7FB579C1D830D30F96AE8E13EF7?lui=ez723q4d&mContainer=2&mOwner=G30392x2n39372t36

 

 

Non-Medicare Payers 

Non-Medicare third-party payers may also issue coverage determinations. These are often found on the website of the third-party payer. However, in some cases, third-party payers do not issue coverage determinations and instead default to the coverage guidelines of the Part B MAC policies, which have jurisdiction in the state where the services were provided. Therefore, providers should check with each third party to whom they submit claims to see what coverage policies each of their third-party payers have issued. Sometimes, the coverage guidelines for the same service or product may differ from one patient to the next, even within the same practice in the same state, if different third-party payers have other coverage guidelines for the same service. 

 

No Coverage Policy 

Sometimes, a third-party payer needs a coverage policy for a specific service. For example, none of the Part B MACs have an LCD for the service of a bunionectomy. In the absence of a coverage policy, most third-party payers, including the Part B MACs, state coverage, and frequency considerations are based on medical necessity. This includes the presence and documentation of the medical need of the service performed and the product dispensed.  

 

Summary 

Unless providers outsource this type of work, they need to know where to find the third-party payers' coverage guidelines to whom they submit claims. When it comes to Medicare beneficiaries, this means knowing who the provider's Part B MAC and DME MAC are. For non-Medicare payers may require reviewing some policies, depending on how many third-party payers the provider submits claims to. Providers can stay current with these policies by subscribing to the listserv of the third-party payer.