Original Medicare:
Coverage
Deciding whether or not services and items are medically necessary is the key to Medicare coverage and payment. These decisions, or coverage determinations, typically occur at the local level. Local Coverage Determinations (LCDs) are developed by the contractors that process Medicare claims. LCDs apply to the regions or states in which the contractors operate. Medicare, however, also develops National Coverage Determinations (NCDs) that apply to all Medicare claims nationwide.
CMS has more information on the NCD process online. NCDs and LCDs, along with Medicare’s other coverage manuals, lay out the criteria for medical necessity and Medicare coverage. These must be met in order for Medicare to pay for services.
HAP Resources
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Booklet: Accessing the Care in Medicare
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Tool: Preventive Benefits | National and Local Coverate Determinations |
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Summary: Medicare National and Local Coverage Determinations and Medical Necessity Decisions |
| Home Health Care |
- Issue Brief: Staying at Home: A Guide to the Medicare Home Health Benefit
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CMS Resources
- Database: Medicare Coverage Determinations
