Medical Necessity and Local Coverage Determinations (LCDs)

Medicare Claims Review Program (MR, NCCI Edits, MUEs, CERT and RAC) (October 2008)
CMS has published a new educational resource discussing the Medicare Claims Review Program is now available on the CMS website. This booklet provides an overview of the several initiatives implemented by CMS to prevent improper payments before a claim is processed and identify and recoup improper payments after a claim has been processed.  To access this new product, visit the CMS website

Limiting Access to Inpatient Medical Rehabilitation: A Look at Payment Denials for Medicare Patients Treated in Inpatient Rehabilitation Facilities  (October 2007)

Inpatient Rehabilitation LCDs

Mutual of Omaha (9/4/07) - AK, AL, AR, CA - Entire State, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO - Entire State, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY

On 9/25/07 CMS announced Wisconsin Physicians Service Insurance Corp (WPS) was awarded a Medicare Administrative Contractor (MAC) contract. As a result, Mutual of Omaha Part A business was transferred to WPS on 11/05/07.

Mutual of Omaha LCD (active, effective 9/4/07) 

Palmetto GBA - 11/5/07 - CA, HI, NV, American Samoa, Guam & N. Mariana Islands

Palmetto subcontractors include TrailBlazer, First Coast.


Local Coverage Determinations & Inpatient Rehabilitation Facilities: Questions and Answers  (October 2006)

Medical Review Policy (LMRP) for Inpatient Rehabilitation Medical Necessity (October 21, 2003)
Attached is a brief description of the new medical necessity standards being introduced in several states that is very restrictive and further complicates the current national regulatory comment process.




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