Availability of Coverage Notices to Operating Personnel

120.2 - Availability of Coverage Notices to Operating Personnel (Rev. 1186, Issued: 02-23-07; Effective: 01-01-06; Implementation: 05-23-07) All review personnel should have ready access to a file of general notices regarding coverage for processing review cases involving the issue of limitation on liability. In addition to general notices, the contractor must have a mechanism for identifying and locating correspondence with individual physician/suppliers regarding coverage of particular services or items. This mechanism should meet at least the following minimum requirements: • The contractor must be able to determine if a practitioner or supplier has been sent an explanation, in lieu of, or in addition, to, a routine MSN denial notice, that a type of service or item is not reasonable and necessary. Such explanation may consist of a general notice or may be individual correspondence with the physician/supplier such as is usually found in contractor correspondence units or comparable units. Claims history files can also be checked, but these are generally useful only when the identical item or service in question has been previously denied as not meeting the requirements of §1862(a)(1); • A copy of such an explanation must be readily available to appeal personnel; and • Procedures must be established requiring that a check of all files be made to determine if such an explanation was ever sent before the physician/supplier’s liability is limited. Once a physician/supplier receives an explanation of denial for an item or service after an appeal determination, that determination would be considered a notice that should be readily accessible for future use for a similar claim(s).