Compliance

NCDs, LCDs & LCAs for Covered Signs, Symptoms, Diagnoses & ICD-10 Codes

An Advance Beneficiary Notice of Noncoverage, or ABN, is an acknowledgment by the Medicare beneficiary that they have been notified that the services provided may be deemed as not medically necessary by Medicare and that they are responsible for payment if Medicare denies payment.

Services that Medicare reviews are called National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs). NCDs, LCDs and LCAs provide guidance for administering the ABN form.

To help medical professionals with compliance, Sanford Laboratories provide the following guidelines accessible all in one place:

• Advance Beneficiary Notice of Noncoverage Form (ABN), instructions and training slide show
• Medical Necessity Billing Information
• National Coverage Determinations (NCD) established by the Centers for Medicare and Medicaid Services
• Local Coverage Determinations (LCD) established by Noridian Healthcare Solutions.
• Local Coverage Articles (LCA) contain coding and billing guidelines that complement the LCD.

Advance Beneficiary Notice of Noncoverage Form (ABN)
Whenever a test with limited coverage (NCD, LCD or LCA) is ordered, the laboratory is allowed to submit the test to Medicare for payment. If payment is denied, the laboratory will be able to bill the beneficiary if an Advance Beneficiary Notice of Noncoverage Form was completed. The form regulations apply to participating and nonparticipating provider services that may be determined as not medically necessary.

Under federal law, providers must inform beneficiaries in writing before providing a service which Medicare may consider not medically necessary. Advance Beneficiary Forms also protect the provider's right to collect payment from the beneficiary when claims are denied by Medicare as "not reasonable and necessary."

Medical Necessity Billing Information

If you submit testing to Sanford Laboratories located in Sioux Falls, Rapid City, Fargo or Bismarck and your facility is not located in South Dakota or North Dakota, the NCDs, LCDs and LCAs will still apply to your facility because Sanford Laboratories files Medicare claims with Noridian Healthcare Solutions.

If you submit testing to Sanford Laboratories - Bemidji, and your facility is not located in Minnesota, the NCDs, LCDs and LCAs will still apply to your facility because Sanford Laboratories files Medicare claims with National Government Services.

These files include:

• Information for tests that are sent to Sanford Laboratories and billed to Medicare by Sanford Laboratories
• A guide to determine when an Advance Beneficiary Notice of Noncoverage (ABN) needs to be signed
• Background information
• Limited coverage policies by test