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CMS Proposes New Appeals Process for Medicare Coverage Decisions. August 21, 2002 - The Centers for Medicare & Medicaid Services (CMS) proposed a rule today that would establish a process for beneficiaries to appeal local or national Medicare coverage determinations. The proposed rule provides for independent review of these coverage policies. Under the proposal, appeals of local coverage determinations (LCDs) would be reviewed initially by an administrative law judge (ALJ). Appeals from national coverage determinations (NCDs) and from ALJ decisions on LCDs would be reviewed by the Health and Human Services Departmental Appeals Board. The board's decisions could be appealed to federal court. The proposed rule is a first step toward formal implementation of several provisions of Section 522 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000. Beneficiaries already have the right to appeal individual claims denials when they believe a covered item or service was denied improperly. The proposed rule would give them an additional avenue to challenge the underlying coverage policy. The new appeals process would ensure that complaints are reviewed in a predictable, uniform manner. In addition, decisions in these appeals may have implications for future Medicare coverage of the item or service for all Medicare beneficiaries, not just the individual who filed the appeal. CMS has already implemented a process for any interested party to follow when seeking a change in a national coverage determination. More recently, it has instructed the private insurers that process Medicare claims for CMS to establish and publicize a process, to become effective October 1, for certain interested parties to use to seek reconsideration of a local medical review policy. This is in addition to the process outlined in the proposed rule. "This proposed rule will build on the policies CMS has already put into place to provide beneficiaries with the opportunity to seek review of CMS coverage policies," says CMS Administrator Tom Scully. "Unfortunately, when Congress enacted the BIPA provisions addressing appeals, it did not provide additional funding to the Medicare program for the associated costs. Consequently, this has caused some delays in implementing this new process because CMS has had to reallocate funds from other high priority and Congressionally-mandated activities to underwrite the expanded appeals process." NCDs are made by CMS and must be followed by all contractors that process and pay Medicare claims. LCDs are made by the contractors and apply only in the areas served by the individual contractor. The proposed rule will be published in the Aug. 22 Federal Register. CMS will accept public comments on the proposed rule until Oct. 21, and plans to publish a final rule as soon as practicable after the public comment period is completed.
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