Glossary

In the Original Medicare Plan, 60 days that Medicare will pay for when you are in a hospital more than 90 days during a benefit period. These 60 reserve days can be used only once during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance ($438 in 2004).

Sixty days that Medicare will pay for when you are in a hospital for more than 90 days. These 60 reserve days can be used only once during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance ($406 in 2002).

In the Original Medicare Plan, the highest amount of money you can be charged for a covered service by doctors and other health care suppliers who don’t accept assignment. The limiting charge is 15% over Medicare’s approved amount. The limiting charge only applies to certain services and doesn’t apply to supplies or equipment.

Service or item specific detail of claim.

The surgical procedure of excising a kidney from a living donor and implanting it into a suitable recipient.

A legal document also known as a medical directive or advance directive. It states your wishes regarding life-support or other medical treatment in certain circumstances, usually when death is imminent.

A generic term for code values that are defined for a state or other political subdivision, or for a specific payer. This term is most commonly used to describe HCPCS Level III Codes, but also applies to state-assigned Institutional Revenue Codes, Condition Codes, Occurrence Codes, Value Codes, etc.

A generic term for code values that are defined for a State or other local division or for a specific payer. Commonly used to describe HCPCS Level III Codes.

An LCD, as established by Section 522 of the Benefits Improvement and Protection Act, is a decision by a Medicare Contractor (A/B MAC, DME MAC, HHH MAC, Fiscal Intermediary or Carrier) whether to cover a particular service or item on an contractor-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (i.e., a determination as to whether the service is reasonable and necessary). The difference between LMRPs and LCDs is that LCDs consist only of "reasonable and necessary" information, while LMRPs frequently also contained benefit category or statutory provisions.

For a full description of the process and criteria used in developing LCDs, refer to Chapter 13 of the Medicare Program Integrity Manual.

LMRP was an administrative and educational tool to assist providers, physicians and suppliers in submitting correct claims for payment. They outlined how contractors were to review claims to ensure that they met Medicare coverage requirements.

LMRPs pre-date LCDs; and, were retired in their entirety by December 2005. All LMRP document versions are posted on the MCD Archive. LMRPs could include "reasonable and necessary" information, as well as benefit category and statutory exclusion provisions. LCDs and Articles replaced LMRPs.