Challenging Coverage Determinations

• Section 522 BIPA Challenge
  • This process allows certain Medicare beneficiaries to challenge national coverage determinations(NCDs) and local coverage determinations (LCDs). It implements portions of section 522 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000.
  • The right to challenge NCDs and LCDs is distinct from the existing appeal rights that Medicare beneficiaries have for the adjudication of Medicare claims.
  • Beneficiaries can challenge an entire policy or a specific provision - challenges can result in LCD being retired or revised.
  • Available to beneficiaries - providers may not initiate, but can assist beneficiary
  • FINAL RULE: 42 CFR Parts 400, 405, and 426, Medicare Program: Review of National Coverage Determinations and Local Coverage Determinations, November 7, 2003
• LCD Reconsiderations
  • Providers can request a revision to a final LCD & can submit medical evidence.
  • Description of reconsideration process is on contractor’s websites.
  • Permits experts to make judgments about policies rather than using an ALJ proceeding.
• Claims Adjudication-Appeal Process
  • LCDs are not binding on QICs/ALJs
  • An individual claim can be paid without challenging the applied LCD

For more information, see: Appeals of Local Coverage Determinations, DHHS, January 2007