decisionhealth Newsletters, Answer Books - 2006 Issue 3 (March)
Program_Memos / 2002 / AB-02-139
Subscribe or sign in to view the full article.
Article Overview
This article explains Medicare program guidance for contractors and other intermediaries on handling drugs that may fall under the self-administered drug exclusion. It covers contractor process expectations, publication and reporting duties, notice timing, appeals handling, and the relationship to local coverage materials and reasonable-and-necessary determinations. The memo is relevant to Medicare administrative staff, contractor medical directors, and coding or reimbursement professionals who follow drug coverage policy changes.
Why This Topic Matters
It affects how Medicare contractors document, communicate, and administer coverage decisions for injectable drugs, including notice, publication, and appeal handling requirements. The article also clarifies what contractors should and should not include in local medical review policies and how reporting workflows are managed.
Article Sections
-
Conferences Between Contractors
Discusses optional discussions among contractor medical directors and the extent to which each contractor may independently participate or rely on others’ determinations.
-
Beneficiary Appeals
Addresses beneficiary appeal rights for claim denials tied to the self-administered drug exclusion and describes the general liability implications of those denials.
-
Provider and Physician Appeals
Summarizes appeal pathways available to physicians and hospitals under Medicare manual provisions.
-
Reasonable and Necessary
Explains the broader administrative distinction between medical appropriateness determinations and other coverage or setting-related judgments made by contractors.
-
Reporting Requirements
Describes contractor reporting obligations to CMS, including list maintenance, publication timing, formatting expectations, and implementation dates.
What You Will Learn
- How Medicare contractors are expected to manage self-administered drug exclusion determinations
- What notice and publication responsibilities apply to contractor lists of excluded drugs
- How appeals are handled when a denial is based on a benefit category exclusion
- How contractor responsibilities relate to local medical review policies and reporting workflows
- What administrative timelines and implementation requirements are included in the memorandum
Who Should Read This
- Medicare contractors
- Fiscal intermediaries
- Carriers
- Medical directors
- Hospital reimbursement staff
- Physician practice reimbursement staff
- Coding and compliance professionals
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com