CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medicare Coverage Determination Hierarchy

Defines how Blue Cross & Blue Shield of Rhode Island (BCBSRI) makes coverage determinations for Medicare Advantage members, specifying the hierarchy of National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and other sources and how jurisdictional rules are applied.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedicare Coverage Determination Hierarchy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 17, 2019

Next Review DateN/A

Key ActionProviders must review and follow current CMS NCDs, LCDs and payment policies when making coverage determinations for Medicare Advantage members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4hierarchy steps

CMS NCDs/LCDsprimary guidance

Rhode Islandlocal MACs

12/18/2024last reviewed

Coverage Determination Rules

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Coverage Determination Hierarchy

BCBSRI applies the following hierarchy when making Medicare Advantage coverage determinations:

Step 1 - NCD: If a CMS National Coverage Determination (NCD) exists for the item/service, the NCD is the primary source and governs coverage determinations.

Step 2 - Exclusive MAC LCD: If no NCD exists and there is an exclusive jurisdiction (one Medicare Administrative Contractor has an LCD because there is only one provider/laboratory for the particular item or service), use that MAC's LCD; for proprietary laboratory services the jurisdiction is normally the MAC where the laboratory is located unless the lab is headquartered in another jurisdiction, in which case that jurisdiction's LCD is used.

Step 3 - Rhode Island MAC LCD: If no NCD and no exclusive jurisdiction, BCBSRI utilizes the LCDs under the direction of the Rhode Island regional Medicare Administrative Contractor for coverage determinations.

Step 4 - Peer-reviewed evidence: If no NCD, no exclusive jurisdiction, and no Rhode Island LCD, BCBSRI will apply policy determinations developed from peer-reviewed scientific evidence.

This policy does not specify separate medical necessity criteria for services. For Medicare Advantage members, BCBSRI follows applicable Centers for Medicare & Medicaid Services guidance; coverage and medical necessity determinations are made in accordance with current CMS National Coverage Determinations (NCDs) and, where applicable, Local Coverage Determinations (LCDs).

Provider Responsibilities and Actions

Prior Authorization

Prior Authorization Not Applicable

Prior authorization is not applicable to this policy. Separate rules may apply when services follow CMS NCD/LCD edits.

Documentation Required

Provider Responsibility to Follow CMS Guidance

Providers must review and follow current CMS payment policies, NCDs, and LCDs when submitting claims and requesting services. Ensure documentation supports the medical necessity and diagnosis criteria specified by CMS guidance.

Review applicable NCDs and LCDs before submitting claims
Document how services meet CMS-documented medical necessity criteria

Denial Risk

Denial Risk for Noncompliance with CMS Guidance

Failure to follow CMS payment policies, NCDs, or LCDs may result in coverage denial or claim adjudication consistent with Medicare Advantage rules.

Noncompliance can lead to denial for Medicare Advantage members
Claims must align with the applicable NCD/LCD to avoid payment issues

Billing Rule

Provider Billing and Documentation Obligations

Providers are responsible for billing in accordance with CMS rules and for maintaining documentation that supports coverage determinations. When an NCD or LCD documents criteria for a service, BCBSRI may not issue a separate policy — providers must follow the CMS criteria.

Follow CMS billing and documentation requirements
When CMS criteria exist, those criteria govern even if a BCBSRI policy is not produced

Background

This document addresses administrative coverage determination processes rather than clinical indications. BCBSRI bases internal policy determinations on published guidelines, peer‑reviewed evidence, and specialty society recommendations but, for Medicare Advantage members, gives primacy to CMS coverage guidance: NCDs first, then applicable LCDs, followed by regional MAC direction or peer‑reviewed evidence when no CMS determination exists.

Definitions

Local Coverage Determination (LCD)

DefinitionA Local Coverage Determination (LCD) is a decision by a Medicare Administrative Contractor whether to cover a particular service on a MAC-wide basis; LCDs can include lists of CPT/HCPCS codes and ICD-10-CM codes indicating which services or diagnoses are considered covered or not covered.

Content of LCDsLCDs may list CPT or HCPCS procedure codes and ICD-10-CM diagnosis codes that identify services the LCD applies to and codes for which services are not considered reasonable and necessary.

Role in BCBSRI determinationsWhen no CMS NCD exists, BCBSRI uses applicable LCDs (including exclusive jurisdiction LCDs or Rhode Island MAC LCDs) as a primary source for Medicare Advantage coverage decisions.

ScopeLCDs apply on a MAC-wide basis within the contractor's geographic jurisdiction and guide local coverage and medical necessity determinations.

Medicare Administrative Contractor (MAC)

DefinitionA Medicare Administrative Contractor (MAC) is a private organization contracted with CMS to carry out administrative responsibilities for Medicare Parts A and B within an awarded geographic jurisdiction; MACs are multi-state regional contractors.

ResponsibilitiesMACs perform administrative functions for Medicare Part A and Part B beneficiaries, including issuing Local Coverage Determinations (LCDs) that govern coverage within their jurisdiction.

Jurisdiction exampleRhode Island is served by National Government Services (NGS) for A/B services (part of Jurisdiction K) and by Noridian for certain durable medical equipment (Jurisdiction A).

Guidance roleMAC-issued LCDs and jurisdictional rules inform BCBSRI's Medicare Advantage coverage decisions when NCDs do not apply.

National Coverage Determination (NCD)

DefinitionA National Coverage Determination (NCD) is a coverage determination made by CMS that defines on a national basis whether services, procedures, or technologies are within the scope of a Medicare benefit category and are reasonable and necessary for diagnosis or treatment.

AuthorityWhen a CMS NCD exists for an item or service, the NCD is the primary source and governs BCBSRI's Medicare Advantage coverage determinations.

AccessCMS maintains an NCD alphabetical index in the Medicare Coverage Database to locate national coverage policies and determinations.