Medicare Administrative Contractors (MAC)

Think back to the most recent visit to your doctor’s office. You probably signed some consent forms and let the receptionist make a copy of your Medicare card. However, did you know that when your doctor submits their claim for payment, it actually goes to a private healthcare insurer for processing?

This insurer ­­­– called a Medicare Administrative Contractor (MAC) – also determines whether certain items and services you might need are covered. This article discusses the role that MACs play and how to find information about your coverage.

What Is a MAC?

Think of a MAC as a middleperson between you, your doctor and the Centers for Medicare & Medicaid Services (CMS). Each geographic region (also known as jurisdiction) has a specific MAC that handles the payment side of the Medicare fee-for-service program. MACs are also charged with conducting audits and educating providers.

How Many Macs Exist?

Currently, there are 12 Medicare Part A and B MACs that assist with Original Medicare (Medicare Parts A and B). Four of these MACs also process home health and hospice claims in addition to their typical Medicare Part A and Part B claims. There are also four durable medical equipment (DME) MACs.

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How Do I Know Which MAC Is in My State?

CMS provides a list of MACs by state.

You can also use this interactive state-specific resource. Simply click on your state where you’ll find a link to all relevant MACs. For example, if you live in Rhode Island, your Medicare Part A/B MAC is National Government Services, Inc., the MAC for jurisdiction K. This MAC also assists with home health and hospice claims. However, your DME MAC is Noridian Healthcare Solutions, LLC., the MAC for jurisdiction A. Each MAC’s name is hyperlinked to its website where you can read more information.

Why Are MACs Important?

MACs are important because they ensure your doctor gets paid correctly. They also create what’s called local coverage determinations (LCD) based on whether an item or service is considered reasonable and necessary. LCDs exist in the absence of a national coverage policy, and they may vary from jurisdiction to jurisdiction.

To view your MAC’s LCDs, head over to the Medicare Coverage Database. Then select ‘local coverage final LCDs by state report,’ and select your state. From there, you can click on specific LCDs to read more.

When Would I Need to Find a Specific LCD?

You might need to find an LCD if you’re filing an LCD challenge.

You can do this if you have Medicare Part A, Medicare Part B (or both), and you need the item or service that’s not covered by the LCD. However, you need to file your request within six months of the date of the treating doctor’s written statement that you need the item or service.

If you’ve already gotten the item or service, you need to file it within 120 days of the date of the initial denial notice from the MAC that used the LCD. Your Medicare Summary Notice will explain what was charged and paid as well as whether a specific LCD influenced coverage and payment.

To file the actual LCD challenge, you’ll need to provide the title of the LCD you’re challenging, the specific provision of the LCD affecting you, and several other details. Don’t send your appeal directly to your MAC. Instead, send it to the Department of Health & Human Services, Departmental Appeals Board MS 6132, Civil Remedies Division, 330 Independence Ave. S.W., Cohen Building Room G-644, Washington, DC 20201.