CMS Announces Updates to Medicare Secondary Payer Compliance in April/May 2023

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On May 16, 2023, CMS Announced its updated Version 3.9 of the Workers Compensation Medicare Set-Aside Arrangements (WCMSA) Reference Guide available to download at  Workers’ Compensation Medicare Set Aside Arrangements.

We bullet point the changes in this latest version as follows:

  • All WC letters currently signed with CMS’ Director of Financial Services Group name and signature image have been updated to reflect the current CMS customer service contact information.  Sample letters are available to view in Appendix 5, pgs. 78-94.
  • The CMS Regional Offices are no longer responsible for approving initial determinations. Process language and contact information have been updated throughout the guide (Sections 9.0, 9.4.6, 9.5, and 18.0, and Appendix 5).   Review the WCRC Medical Review Steps diagram (Pg. 15).
  • Clarification has been provided regarding intrathecal pump, spinal cord stimulator, and peripheral nerve stimulator replacement frequency calculation (Section 9.4.5).

In this section CMS provides transparency into the CPT and HCPCS codes used for these medical devices as well as the frequency of placement and replacements of these devices with formulaic examples.  This is useful not only for properly allocating medical devices in MSAs destined for CMS approval, but useful in identifying any CMS errors in the review process, involving these devices, and determining when a Re-review request may be appropriate. 

  • The maximum time limit for eligibility has been removed from the Amended Review process (Section 16.3) allowing more time for a Re-review of an MSA. 

CMS will allow a one-time request for re-review when the following criteria are met:

  1. CMS issued a conditional approval or approved the MSA at least 12 months prior. 
  2. The claim has not been settled, as of the date of the request for re-review.
  3. The projected medical care has changed significantly, and the submitter’s new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount. 
  • The 94585 ZIP code has been added to the Walnut Creek Medical Center in the table listing major medical centers (Appendix 7).
  • The CDC Life Table link was updated (Section 10.3).

CMS Announced that beginning April 29, 2023, CMS will utilize the CDC’s “Table 1: Life Table for the total population: United States, 2020” for the Workers’ Compensation Medicare Set Aside life expectancy calculations. A link to the CDC’s 2020 Life Tables can be found at  .  Our clients will notice that all MSA reports reference the updated Life Table, accordingly. 

On April 27 CMS Released the Non-Group Health Plan (NGHP) Applicable Plan Appeals Reference Guide, Version 1.0.  This guide was created for the purpose of providing NGHPs, or applicable plans and authorized representatives, a summary of requirements and guidance when submitting appeals for Medicare Secondary Payer Conditional Payment demands. 

This is an excellent resource for professionals to understand the negotiation process, the levels of Appeal and CMS time frames to resolve Conditional Payment disputes.

On April 24, 2023, CMS released Version 7.1 Non-Group Health (NGHP) MMSEA Section 111, Medicare Secondary Payer Mandatory Reporting User Guide.  

For agents, Responsible Reporting Entities (RREs) and administrators, the Guide may be found at   Carefully review the changes to subscription insurance policies and the Unsolicited Response File in Table F-2. 

On June 6, 2023 at 1:00pm EST, CMS Will host a Section 111 Non-Group Health Plan (NGHP) Unsolicited Response File Webinar , so mark your calendar to participate and learn more!

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