Sep

22

CMS clarifies RACs’ ‘exception authority’

By Medicare Weekly Update

By Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.

On September 11, CMS published Transmittal 302 that updated the Program Integrity Manual on Local Coverage Determination (LCD) exceptions. When specific authorized contractors conduct a complex medical review, they have the authority (in rare and unusual circumstances) to apply an exception to the “reasonable and necessary” requirements described in an LCD to approve or deny a claim.  However, they cannot make exceptions to National Coverage Determinations (NCDs). In addition, and unless otherwise directed by CMS, RACs can only use the exceptions process to not deny a claim.  This is a good time to review the difference between a national and a local coverage determination policy.

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