Local and National Coverage Determinations

National Coverage Determination (NCD)

NCDs are national policy statements issued by CMS that outline whether Medicare will pay for specific medical services, procedures, or devices. These determinations are binding for all Medicare Administrative Contractors (MACs) across the country. The NCD process typically involves:

• Formal request or internal CMS initiation
• Evidence review
• Public comment period
• Final decision making

Local Coverage Determination (LCD)

LCDs are coverage decisions made by MACs for their specific geographic areas. They cannot conflict with NCDs but can provide additional guidance where no NCD exists or provide specific details about implementation. The LCD process includes:

• Proposed LCD publication
• Public comment period (minimum 45 days)
• Contractor Advisory Committee (CAC) review
• Final LCD publication 

Medicare Administrative Contractors (MACs)

MACs are private healthcare insurers that have been awarded geographic jurisdictions to process Medicare Part A and Part B medical claims. They are mainly responsible for:

• Processing Medicare claims for hospitals, skilled nursing facilities, home health agencies, and other healthcare providers
• Making local coverage determinations (LCDs)
• Enrolling providers in the Medicare program
• Managing appeals and hearings for denied claims 

Current MAC Structure:

• There are 12 Part A/B MAC jurisdictions across the United States
• Each jurisdiction serves a specific geographic region