Decision by a Medicare fiscal intermediary whether to cover a particular service on an intermediary-wide or carrier-wide basis in accordance with the Social Security Act. This determination is based on whether the service is considered reasonable and necessary. The difference between local medical review policies (LMRPs) is that LCDs consist of only “reasonable and necessary” information, whereas LMRPs may also contain cate- gory or statutory provisions. Formerly known as local medical review policy (LMRP) .

Regional guideline or rule used to make local Medicare medical coverage decisions because a national coverage regulation is absent. Such policies were developed after review of medical literature, local practice, and comments from the medical community and Carrier Advisory Committee. Beginning December 7, 2003, all LMRPs were converted to local coverage determinations (LCDs). See local coverage determination (LCD) .

Certain geographical region (state, county, aggregation of counties, parts of counties, population density, metropolitan size, or townships) within which Medicare carriers or fiscal intermediaries establish prevailing charges. Also called area .

Three-digit number that represents a group of zip codes.

1. Place of service (POS) where a medical service is performed such as a hospital (inpatient or outpatient), doctor’s office, or skilled nursing facility. When the physician’s office or an outpatient hospital is billing, the two-digit POS code is inserted in Block 24B of the CMS-1500 insurance claim form (e.g., 11 is doctor’s office and 12 is patient’s home). 2. Anatomical location of a medical problem.

Distribution of insurance products by finding insurance offices and agents in locations where consumers commonly shop for groceries or take care of other personal or business matters. Also known as retail outlet distribution system .

In managed care plans and health maintenance organizations, a provision in which members must receive their medical care from the network providers unless it is an emergency.