Compliance

NCDs & LCDs 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) and Local Coverage Determinations (LCDs). NCDs and LCDs 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 Medicare Noridian of North Dakota

Advance Beneficiary Notice of Noncoverage Form (ABN)
Whenever a test with limited coverage (NCD or LCD) 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 (in Sioux Falls, Rapid City, Fargo or Bismarck) and your facility is not located in South Dakota or North Dakota, the NCDs and North Dakota LCDs still apply to your facility because Sanford Laboratories (in Sioux Falls, Rapid City, Fargo or Bismarck) files its Medicare claims with Medicare Noridian of North Dakota.

If you submit testing to Sanford Laboratories - Bemidji, the NCDs and Minnesota LCDs apply to your facility because Sanford Laboratories - Bemidji files its Medicare claims with National Government Services Inc. of Minnesota.

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