CMS Pub. 100-08, ch. 1, § 1.4

MACs:

The MACs shall employ a minimum of two FTEs contractor medical director (CMD) and

arrange for an alternate when the CMD is unavailable for extended periods. The CMD

FTEs shall be composed of either a Doctor of Medicine or a Doctor of Osteopathy. All

clinicians employed or retained as consultants shall be currently licensed to practice

medicine in the United States, and the contractor shall periodically verify that the license

is current. When recruiting CMDs, contractors shall give preference to physicians who

have patient care experience and are actively involved in the practice of medicine. The

CMD's duties are listed below.

Primary duties include:

• Leadership in the provider community, including:

o Interacting with medical societies and peer groups;

o Educating providers, individually or as a group, regarding identified problems

or LCDs; and

o Acting as co-chair of the Contractor Advisory Committee (CAC) (see chapter

13 §13.8.1.4 of this manual for co-chair responsibilities).

• Providing the clinical expertise and judgment to develop LCDs and internal MR

guidelines:

o Serving as a readily available source of medical information to provide

guidance in questionable claims review situations;

o Determining when LCDs are needed or must be revised to address program

abuse;

o Assuring that LCDs and associated internal guidelines are appropriate;

o Briefing and directing personnel on the correct application of policy during

claim adjudication, including through written internal claim review

guidelines;

o Selecting consultants licensed in the pertinent fields of medicine for expert

input into the development of LCDs and internal guidelines;

o Keeping abreast of medical practice and technology changes that may result in

improper billing or program abuse;

o Providing the clinical expertise and judgment to effectively focus MR on

areas of potential fraud and abuse; and

o Serving as a readily available source of medical information to provide

guidance in questionable situations.

Other duties include:

• Interacting with the CMDs at other contractors to share information on potential

problem areas;

• Participating in CMD clinical workgroups, as appropriate; and

Upon request, providing input to CO on national coverage and payment policy, including

recommendations for relative value unit (RVU) assignments.

SMRC:

Primary duties include:

• Serving as a readily available source of medical information to provide guidance

in questionable claims review situations

• Providing the clinical expertise and judgment to develop LCDs and internal MR

guidelines

• Keeping abreast of medical practice and technology changes that may result in

improper billing or program abuse

• Providing clinical expertise and judgment to effectively focus MR on areas of

potential fraud and abuse

• Serving as a readily available source of medical information to provide guidance

in questionable situations