Highmark Medicare Services is the Centers for Medicare and Medicaid Services' (CMS) contracted Fiscal Intermediary for the Medicare fee-for-service program for most Pennsylvania hospitals.  It is also the Fiscal Intermediary for skilled nursing facilities, renal dialysis facilities, rural health clinics, comprehensive outpatient rehabilitation facilities, and community mental health centers in a multi-state region. As a Fiscal Intermediary, Highmark Medicare Services is responsible for developing Local Medical Review Policies/Local Coverage Determinations, (LMRP/LCDs), for institutional or facility providers of care. 

We are also a Part B Medicare Carrier for Pennsylvania that applies the Medicare coverage rules for services by physicians and medical suppliers, including but not limited to, clinical laboratory and diagnostic services, ambulance services and services provided by individual practitioners.

LMRP/LCDs are developed to clarify the conditions under which the use of medical devices, procedures, or medications, are generally considered reasonable and necessary.  They are to represent the local community standard of care. 

Local policies outline how contractors will review claims to ensure that they meet Medicare coverage requirements. LMRP/LCDs must be consistent with national guidance (although they can be more detailed or specific), developed with input from medical professionals (through advisory committees), and consistent with scientific evidence and clinical practice.

Contractors are also required to have an open and public process for the development of LMRP/LCDs. The development process parallels the national coverage determination development process, providing more notice and opportunity for providers and other interested parties to have input into the policies.

If you would like to participate in the comment process you may do so in our draft policy area.