CMS Pub. 100-08, ch. 3, § 3.6.3

This section applies to MACs, CERT, RACs, and UPICs, as indicated.

A. General

If a claim is denied through prepayment or postpayment review, the MAC shall notify the

beneficiary consistent with the requirements in PIM chapter 3, §3.6.2.3. The MAC shall

include limitation of liability and appeals information. Notification can occur via

Medicare Summary Notice (MSN). The CERT, RACs, and UPICs are not required to

issue beneficiary notices for claims they deny. Instead, CERT, RACs, and UPICs shall

communicate sufficient information to the MAC to allow the MAC to develop an

appropriate beneficiary notice.

The MACs are required to give notice to Medicare beneficiaries when claims are denied

in part or in whole based on application of a LCD. All denials that result from LCDs shall

provide the MSN message 15.19 in addition to the current applicable message. Message

15.19 states (IOM Pub. 100-04, chapter 21):

“A local coverage determination (LCD) was used when we made

this decision. A LCD provides a guide to assist in determining

whether a particular item or service is covered by Medicare. A copy

of this policy is available from your local intermediary, carrier or

(Medicare Administrative Contractor) by calling the number in the

customer service information box on page one. You can compare the

facts in your case to the guidelines set out in the LCD to see whether

additional information from your physician would change our

decision.”

The MACs shall make these messages available in Spanish where appropriate. The 15.19

portion of the MSN message states:

Una Determinación de Cobertura Local (LCD, por sus siglas en

inglés) fue utilizada cuando se tomó esta decisión. La LCD es una

guía que ayuda a determinar si un artículo o servicio en particular

está cubierto por Medicare. Una copia de esta póliza está disponible

en su intermediario, local o en su empresa de seguros Medicare, o en

su Contratista Administrative de Medicare, al llamar al número que

aparece en la información de Servicios al Cliente en la página uno.

Usted puede comparar los datos de su caso con las reglas

establecidas en la LCD para ver si obteniendo información adicional

de su médico pudiera cambiar nuestra decisión.

The MACs shall use the above message in every instance of a prepayment denial where a

LCD was used in reviewing the claim. Use this message, and message 15.20 (now for

FISS MACs, and when 15.20 is fully implemented for contractors on the MCS/VMS

systems) on both full and partial denials, whether the denial was made following

automated, non-medical review, or medical record review. MACs shall not use this

message on denials not involving LCDs. For claims reviewed on a postpayment basis,

include the language exactly as contained in the MSN message above if sending the

beneficiary a new MSN. If sending a letter, include the language exactly as contained in

the MSN message above. Message 15.20 currently states:

“The following policies [insert LCD ID# and NCD#] were used when we made this

decision.”(Pub.100-04, chapter 21).

The MACs shall continue to use 15.19 in conjunction with the MSN message 15.20,

where 15.19 is applicable. MACs should, at their discretion, combine these messages if

necessary, but 15.19 shall not be deleted.

In the case where the results of claims sampling are extrapolated to the universe, only

those beneficiaries in the sample need to be notified. In RAC cases, the RAC and MAC

Joint Operating Agreement (JOA) shall specify what information the RAC will supply to

allow the MAC to notify the beneficiary when re-adjudication results in a change to the

initial determination.