Medicare Conditional Payments Archives - Page 2 of 3

November CMS News: Mandatory Reporting and Conditional Payment Updates

November 24, 2020

Hand writing What's New?" on a chalkboard for CMS news update

Here’s a recap of recently announced CMS news:

CMS News #1: Medicare Conditional Payment Appeals Guide

In follow-up to its September 2020 webinar on Medicare conditional payment appeals through the Commercial Repayment Center (CRC), CMS converted the slides into an appeals guide. The guide, which can be found here, provides a breakdown of the Medicare conditional payment appeals process and the bases for appeals.

CMS News #2: Updated MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting Guide

Earlier in November, CMS released a Technical Alert and an updated MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting User Guide, Version 6.1, to announce “Section 111 Edits to no Longer Cause Record to Reject.”

In short, starting April 5, 2021, several error codes will be converted into what CMS calls “soft edits.” Soft edits are still considered errors by CMS but will not cause the entire record to be rejected. Examples of such data errors are in fields reporting middle initial of claimant’s name and alleged cause of injury. The Responsible Reporting Entity (RRE) is still responsible for correcting these errors in the next quarterly file submission.

Additionally, a new soft edit will be added and applied to NGHP Claim Input File Detail Record files when users submit a no-fault insurance claim where the policy limit is less than $1000.00. The input files will be accepted but a new CP13 error will be returned on the response files.

Finally, Claim Input File Detail Records submitted prior to the effective date of the injured party’s entitlement to Medicare will be rejected and returned with a Disposition Code ‘03’ instead of an SP31 error. As a result, if the purpose of the report was to indicate ongoing responsibility for medicals has been accepted (ORM=Y), then the claim will need to be re-submitted in the next quarterly reporting period (at which point the claimant is presumably entitled to Medicare).

CMS News #3: CMS to Host BCRC Recovery Process Webinar

On Wednesday, December 9, 2020 at 1:00 PM ET, CMS will be hosting a webinar focused on the Medicare Secondary Payer (MSP) recovery process when a Medicare beneficiary receives a settlement, judgment, award, or other payment. In other words, following its September webinar featuring the CRC, CMS is now highlighting the work of its Benefits Coordination and Recovery Center (BCRC). The announcement can be found here.

Per the announcement:

The primary intended audience is attorneys who represent beneficiaries and other beneficiary representatives. The BCRC will present a refresher on the beneficiary recovery process, including what functions can be facilitated using the Medicare Secondary Payer Recovery Portal (MSPRP). Such functions include submission of authorizations, requesting a Final Conditional Payment, and electronic payments. The webinar will also discuss alternative demand calculation options (Self-Calculated Conditional Payment Amount and Fixed Percentage Option), as well as other beneficiary recovery tips and best practices. The presentation will be followed by a question and answer session with participants.

We encourage anyone who is new to Medicare conditional payment recovery through the BCRC or would like, as CMS indicates, a refresher, to attend the webinar.

If you have any questions regarding these announcements, please contact Tower’s chief compliance officer, Dan Anders, at daniel.anders@towermsa.com or 888.331.4941.

$750 Medicare Conditional Payment Recovery Threshold Remains for 2021

CMS Introduces Pre-CPNs and Open Debt Reports in Conditional Payment Recovery Process

CMS Provides Notices on Section 111 Reporting and Conditional Payment Processes

June 17, 2020

People using laptop and mobile phones to update Section 111 Reporting

CMS has recently issued two notices, one pertaining to mandatory Section 111 reporting and one relevant to Medicare conditional payment recovery.

First, in a “teaser” notice, CMS announced that on July 13, 2020 the Medicare Secondary Payer Recovery Portal (MSPRP) is scheduled to be enhanced to allow authorized users to view and print correspondence.

According to the notice,

MSPRP users who log in using Multi Factor Authentication will be able to view and print CMS mailed correspondence that is displayed on the Letter Activity tab. Additional information on how to use this new functionality will be available in Section 14.1.1.4 of the July version of the MSPRP User Guide.

Second, in an alert entitled “Reporting No-Fault Insurance Limit on Non-Group Health Plan (NGHP) Claim Input Files,” CMS reminds Responsible Reporting Entities (RREs) that they must combine both Med Pay and Personal Injury Protection (PIP) coverage limits for Section 111 reporting purposes. This would be under circumstances where separate Med Pay and PIP coverages are being paid out on claims for the same injured party and incident under a single policy.

CMS also reminded RREs that ORM cannot be terminated until both Med Pay and PIP coverage limits are exhausted. Further, that when providing the dollar amount for the policy limit, that it must accurately reflect two decimal places. For example, a policy limits of $5,000 should be reported as 500000.

Practical Implications

In regard to the MSPRP enhancement to print documents, while we will have to see the specific guidance in the July update, this may prove quite useful in not having to wait for correspondence to come in the mail, print letters that were not received via the mail or reprint letters.

As for the alert to remind No-Fault carriers to report Med Pay and PIP coverage limits as a combined amount, while this guidance is already included in the NGHP User Guide, there was apparently some confusion that led CMS to provide this alert as a reminder of how such coverage must be reported.

If you have any questions, please contact Dan Anders, Chief Compliance Officer at daniel.anders@towermsa.com or 888.331.4941.

CMS Introduces Pre-CPNs and Open Debt Reports in Conditional Payment Recovery Process

January 28, 2020

hands on a laptop sending an email with dollar sign icons spilling out

On January 14, 2020 CMS held a Town Hall to discuss common Commercial Repayment Center (CRC) NGHP ORM Recovery topics. In attendance on the call were various officials from CMS as well as Performant Recovery the CRC contractor. For the most part, the presentation reiterated well-known Medicare conditional payment processes such as differences between conditional payment letters and notices, responding to demand letters and procedures and timelines to dispute and appeal conditional payments.

The slides and notes from the presentation can be found here.

CMS also introduced and explained Pre-CPN Worksheets and Open Debt Reports which we summarize below:

Pre-CPN Worksheet

A Pre-CPN worksheet contains cases that have been reported through the Section 111 reporting process, but for which the CRC has yet to issue a CPN. The purpose of this optional worksheet is for the employer or carrier debtor to identify debts which will not be disputed. Important, it is only accessible to Account Managers for Responsible Reporting Entities (RREs) by contacting the CRC with the entity’s tax identification number and RRE ID.

It is expected the Pre-CPN worksheet will contain claim numbers and the total amount of the claimed debt, but it is uncertain whether it will itemize conditional payment charges. Once reviewed, it is returned to the CRC with an indication of what claims will not be disputed. The CRC then moves forward with issuing the CPN.

Open Debt Reports

The CRC advised that Open Debt Reports are now available in the MSPRP on all cases where the RRE insurer is the debtor and where there is a balance due. The Open Debt Report is only available to the debtor (the RRE) meaning recovery agents, such as Tower, cannot access the reports.

Open Debt Reports are helpful in confirming not only that the RRE is aware of the debt but that the status of the debt, i.e. on appeal, matches their expectation of the status of the debt with the CRC. If a debt is unknown or the status does not match what is expected, then it provides an opportunity to contact the CRC and clarify the matter.

Q&A Session

Following the formal presentation there was a Q & A session which provided the following notable takeaways:

Treasury Department notices: A question asked whether more information, such as a claim number, can be included on Treasury Department collection notices. CMS advised that as the Treasury Dept. collects for the entire federal government it is difficult for Treasury to add information specific to one government program.

Charges unrelated to the injury: Another question asked whether any efforts are being made to reduce the number of unrelated charges found on conditional payment letters and notices. CMS responded that efforts are being made to improve the “grouper” algorithm that searches Medicare billing records to identify charges related to the WC injury. CMS indicated they have an outside contractor reviewing the methodology.

Statute of limitations on Medicare conditional payment recovery: CMS responded to a question on the statute of limitations on Medicare conditional payment recovery by stating that the three-year statute of limitations added to the MSP Act by the SMART Act in 2013 does not apply to its administrative recovery efforts, rather it only applies to legal actions taken by the federal government.

Practical Implications

In regard to the Pre-CPN, it should be reiterated that this is optional. If, as we expect, the worksheet does not itemize conditional payment charges related to the claim, then we are uncertain as to the usefulness of this document.

Turning to the Open Debt Report, this can be a very useful document in confirming an employer or carrier’s current Medicare debts assuming it is accurate. However, as a recovery agent for many RREs, we are disappointed that the CRC is only making these reports available to the RRE who registers for access through the MSPRP and not directly providing to the recovery agent for the RRE.

Notably, CMS’s position on the three-year statute of limitations for conditional payment recovery only applying to legal actions and not administrative actions raises uncertainty for both payors and claimants as to exactly how long Medicare has to recover. Our expectation is that this will ultimately be resolved in the courts.

Finally, we are well aware of conditional payment notices and demands containing numerous charges unrelated to the injury. Often the entire conditional payment claim by Medicare is unrelated. We hope efforts by CMS and the CRC with adjusting this so-called grouper algorithm results in less unrelated charges in the future.

If you have any questions about the Town Hall call or the issues addressed above, please contact Dan Anders at daniel.anders@towermsa.com or 888.331.4941.

CMS to Hold Town Hall on Medicare Conditional Payment Matters

December 9, 2019

Red Medicare button on a keyboard to illustrate Medicare conditional payment.

The Centers for Medicare and Medicaid Services (CMS) recently announced a town hall “to discuss common Commercial Repayment Center (CRC) NGHP ORM Recovery topics.” The town hall will be held on Tuesday, January 14, 2020 (There is a typo in CMS’s announcement which lists 2019) at 1:00 PM ET. The notice can be found here.

When CMS says NGHP, it is referring to Non-Group Health Plans, namely conditional payment recovery in workers’ compensation, liability and no-fault claims. Further, ORM, refers to the acceptance of Ongoing Responsibility for Medicals which is reported through the Section 111 Mandatory Insurer Reporting in process.

CMS’s notice provides little detail of what is to be discussed except for stating, “(t)he format will be opening remarks by CMS followed by a brief presentation, and then questions and answers with the audience.” We encourage anyone involved in Medicare conditional payment recovery, especially in WC and no-fault matters where ORM is regularly reported, to attend the town hall and also be ready with any questions. You can also submit questions prior to the town hall to COBR-NGHP-Comments@cms.hhs.gov.

Tower will provide a summary and key takeaways from the town hall call after its conclusion.

Magic Number Remains $750 for Medicare Conditional Payment Recovery

December 3, 2019

chart, dollars and a fountain pen illustrating conditional paument recovery threshold post

In a 11/26/2019 Alert, the Centers for Medicare and Medicaid Services (CMS) announced that the 2020 recovery threshold for liability, no-fault and workers’ compensation settlements will remain at $750. Accordingly, Total Payment Obligations to the Claimant, TPOCs, in the amount of $750 or less are not required to be reported to CMS through the Section 111 Mandatory Reporting process, nor will CMS attempt to recover conditional payments for TPOCs of this amount (The threshold does not apply to liability settlements for alleged ingestion, implantation or exposure cases).

By way of background, pursuant to the SMART Act of 2012, CMS is required to annually determine a threshold amount such that the cost of collection does not outstrip the amount recovered through such collection efforts. CMS’s calculations, which can be found here, resulted in the $750 threshold being maintained.

Practical Implications

As CMS is keeping the $750 threshold for mandatory reporting and conditional payment recovery there are no changes to the reporting processes or determinations as to when conditional payments should be investigated or resolved.

Everything You Wanted to Know About Conditional Payments But Were Afraid To Ask

September 27, 2019

banner for 2019 tower msa partners webinar details

In light of the positive response to our July webinar, “Everything you wanted to know about MSAs, but were afraid to ask,” Tower will tackle Medicare conditional payments and related topics in our next webinar, October 23 at 2 p.m. ET.

Tower’s Chief Compliance Officer, Dan Anders, will discuss a host of issues related to Medicare conditional payments, address how critical Mandatory Insurer Reporting is to Medicare’s recovery efforts and examine questions surrounding Medicare Advantage plan reimbursement.

Here are just a few of the questions that will be answered:

When do I really need to investigate and resolve Medicare conditional payments?
Will CMS demand reimbursement in a denied claim?
What happens when ongoing going responsibility for medicals (ORM) is mistakenly not reported at time of settlement?
What are the arguments that successfully reduce or eliminate CP demands?
Are there penalties for improper Mandatory Insurer Reporting?
Is a Medicare Advantage Plan really going to assert a recovery claim?

If you want to know more about the how and why of Medicare conditional payments, this free webinar is for you. And, if there is something about Medicare conditional payments you’ve always wondered about, ask us! When you click on the link below to register, you can also submit a question to be answered during the webinar.

Hope you can join us on October 23 at 2 pm ET!

Dan Anders

Chief Compliance Officer

Enhancements to MSPRP Improve Conditional Payment Processes

July 27, 2018

Since its introduction six years ago, the Medicare Secondary Payer Recovery Portal (MSPRP) has increasingly become more reliable and useful in communicating to and receiving information from the Medicare conditional payment recovery contractors (BCRC and CRC). Earlier this month, a revised version of the MSPRP User Guide was released (Version 4.2) and provided for further enhancements to the portal:

To reduce the number of calls received by the BCRC regarding the status of case correspondence, a new read-only Letter Activity tab has been added to the Case Information page, which displays correspondence that has been received or letters that have been sent related to a Benefits Coordination & Recovery Center (BCRC) or Commercial Repayment Center (CRC) case (Section 13.1.1).
To make MSPRP more consistent so that both insurers and beneficiaries (and their representatives) can request electronic letters, the MSPRP now allows insurers, recovery agents on the Tax Identification Number (TIN) reference file, and insurer representatives with a verified Recovery Agent Authorization, who also log in using multi-factor authentication, to request electronic conditional payment letters (eCPLs) for BCRC and CRC insurer-debtor cases (Sections 13.1.5 and 14.5.4). Note: eCPLs may also be requested on cases that are in bankruptcy.
To help Account Managers (AMs) determine which currently active designees should be deleted because of long inactivity on an account, a Last Login Date column has been added to the Designee Listing page (Section 8.3.2).
In cases where Part A, non-inpatient, claims do not have a HCPCS or DRG code associated with them, the Primary Diagnosis Code will appear on the Payment Summary Form (PSF), in bold, under the DX Codes column, along with an explanatory footnote. When the Primary Diagnosis Code is bolded, the HCPCS/DRG column will be blank (Table 13-8).

Practical Implications

Tower MSA staff often spend hours on the phone with the CRC and BCRC to ensure correspondence, such as an authorization, was received and that a matter is progressing to completion. The addition of a Letter Activity tab confirming correspondence has been received and acted upon is a significant benefit as long as the recovery contractors properly update it with the most current documentation received.

Additionally, the ability for an insurer or Tower MSA, on behalf of an insurer, to request an electronic conditional payment letter (eCPL) provides for a more expeditious turnaround time in obtaining this letter which is otherwise sent through the mail. Previously, eCPLs were only available to Medicare beneficiaries.

Update on New Commercial Repayment Center

Since the transition from CGI Federal to Performant Financial as the CRC contractor in February 2018, Tower MSA has encountered a reasonably quick turnaround time (Less than 30 days) in receiving Medicare conditional payment information. Interestingly, in the first few months following the contractor transition the CRC had been issuing Conditional Payment Letters (CPLs), rather than the Conditional Payment Notices (CPNs) (The difference being that a CPL does not have a 30 day time-frame to dispute conditional payments, nor is it followed by a Demand Letter). However, we are now seeing the CRC again issuing CPNs followed by Demand Letters.

While obtaining an itemization of Medicare conditional payments has been a smooth process with the new contractor, the same cannot be said for disputes and appeals of those conditional payments. Our understanding is the new contractor inherited a backlog of these disputes and appeals and has been working through them which has added to the time needed to process new disputes and appeals (Hence the likely reason CPLs were issued rather than CPNs in the first few months of the new contractor). Some disputes and appeals are pending for more than 60 days. Additionally, there have been systematic issues at the CRC resulting in lost disputes/appeals, demand letters issued while disputes are pending and matters prematurely being referred to the Treasury Department for collection activities.

Tower MSA has been advised by Performant that it is continuing to reduce the backlog of dispute and appeal submissions while also addressing the systematic problems. We are optimistic the portal enhancements and Performant acting to reduce the backlog and the systematic challenges will increase the efficiency of the conditional payment process over time. Tower MSA will continue to monitor these processes and when warranted reach out to the CRC to request corrective action be taken.

CRC Contractor Change Brings New Team to Medicare Conditional Payment Recovery Efforts

January 21, 2018

On Thursday, January 18, 2018, the Centers for Medicare and Medicaid Services (CMS) held a webinar to introduce the new Commercial Repayment Center (CRC) contractor, Performant Recovery, and Performant’s management team. This transition to a new contractor is important to insurers and employers as the CRC is responsible for the recovery of Medicare conditional payments against these entities stemming from liability, workers’ compensation and no-fault claims where ongoing responsibility for medicals has been accepted.

Ted Doyle, the Performant MSP CRC Project Director, emphasized in his introductory remarks and throughout the presentation that their main goal is to make the transition seamless for all those who engage with the CRC. His message to stakeholders is CMS’s recovery processes and timeframes remain the same, it is only the entity handling those processes that is changing.

Besides Mr. Doyle, other webinar participants were John Albert, the Director of the CMS Division of Medicare Benefit Coordination and Laura Martinez, the MSP CRC NGHP Recovery Manager for Performant.

Key contractor transition information provided during the webinar was as follows:

The current CRC contractor, CGI Federal, will cease operations effective Friday, February 9, 2018.
Performant Recovery will commence CRC operations effective Monday, February 12, 2018.
Transition cutover, or what CMS calls “Dark Days,” will occur on February 8 and 9. During this period while CGI Federal will continue to answer telephone calls and the Medicare Secondary Payer Recovery Portal (MSPRP) will be available, the information will be limited to what was available at close of business on February 7. Also, uploading documents through the MSPRP will not be available.
Performant will go live as of 8am EST on February 12 at which point the MSPRP will once again be fully available as well as the call center. Correspondence received during the Dark Days or prior to the transition will be transferred to Performant for handling.

In regard to what will remain the same post-transition:

All current cases initiated by CGI will be transitioned to Performant.
Case information, copies of communication, correspondence and contact information, including letters of authority, will be fully accessible to Performant such that there should be no reason for stakeholders to resend correspondence or other information that was previously provided to CGI.
There will be no changes to CMS established recovery processes or timeframes applicable to MSP recovery.
The CRC Call Center will continue the same hours: 8am – 8pm EST
The CRC Call Center phone number will remain the same: (855) 798-2627
All Benefits Coordination and Recovery Center (BCRC) processes remain the same, including Section 111 Mandatory Insurer Reporting.

As for what is changing post-transition:

Effective 2/12/2018* the CRC has a new address:Medicare Commercial Repayment Center – NGHP ORM
P.O. Box 269003
Oklahoma City, OK 73216

*Any correspondence received prior to 2/12/2018 will be held and then processed starting on that date.
Effective 2/12/2018 the CRC fax number is (844) 315-7627.

As with any transition, some bumps are to be expected. We are hopeful these will be short-term and that the transition will not only be seamless, but that Performant improves the customer service aspect of the Medicare conditional payment recovery process. CMS and Performant engaging with Tower MSA and other stakeholders through this webinar is a good first step at building a collaborative relationship with those impacted by the CRC’s recovery efforts.

It was indicated a copy of the presentation slides will be made available on the downloads section of the CMS Coordination of Benefits and Recovery website next week.

If you have any questions regarding the CRC contractor transition, please contact Dan Anders at daniel.anders@towermsa.com or (888) 331-4941.

Daniel Anders, Esq., MSCC

Daniel M. Anders is the Chief Compliance Officer for Tower MSA Partners where he oversees the Medicare Secondary Payer (MSP) compliance program. Dan is an attorney licensed to practice in the State of Illinois and the United States District Court for the Northern District of Illinois.

CMS Releases Annual Report on CRC Conditional Payment Recovery

September 5, 2017

On 8/30/2017 the Centers for Medicare and Medicaid Services released its annual report on the Commercial Repayment Center’s (CRC) Medicare conditional payment collections for the 2016 fiscal year (10/1/2015 through 9/30/2016). In short, the report documents the CRC identified $243.68 million in conditional payments, collected a net of $106.29 million and returned $88.35 million to the Medicare Trust Fund after subtracting collections costs.

The CRC, which is paid on a contingency basis, has responsibility for Medicare conditional payment recovery efforts involving Group Health Plans and Non-Group Health Plans (NGHP). NGHPs are liability insurance (including self-insurance, no-fault insurance or workers’ compensation). FY 2016 was the first fiscal year in which the CRC had responsibility for recovery of conditional payments from NGHPs, a task previously handled by the Benefits Coordination and Recovery Center (BCRC). Recovery claims involving Medicare beneficiaries remain with the BCRC.

A copy of the report may be found on the CMS website here.

Some observations from the report:

CMS does not split out GHP and NGHP recovery information which makes it difficult to ascertain, one, the effect of adding NGHPs to the CRC’s responsibility has had on overall collections and, two, the percentage of overall collections attributable to GHPs versus NGHPs.
Despite identifying $243.68 million on conditional payments, the CRC only recovered $117.40 million, shortly under half (48%) of the identified amounts. This may be the result of the provided data only documenting debts that are identified and collected within the fiscal year. The report indicates that collection of FY 2016 identified debts continues into the next fiscal year.
Connected to the above observation, it is disappointing that the CRC does not provide a more comprehensive multi-year view of its recovery work. Information such as amounts recovered over the past several years, average turnaround time from demand to repayment, and the above-mentioned GHP vs. NGHP data would be invaluable to understanding the overall program.
Provided in the report is a statement indicating amounts returned to the Medicare Trust Fund dropped from $125.05 million in FY 2015 to $88.35 million in FY 2016. CMS attributes the drop to “a decrease in GHP recoveries due in part to the maturity of the mandatory insurer reporting under Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 decreasing the instances of mistaken payments, as well as the CRC’s resolution of pending available recoveries.” This drop is nonetheless surprising given that FY 2016 marked the CRC’s first year recovering from NGHPs!

Takeaways

We do not recommend any changes to your Medicare conditional payment resolution program or process based upon the report. The report merely provides a window into the efforts by the CRC at recovering conditional payments from GHPs and NGHPs.

CMS Announces Portal Functionality for Final Conditional Payment Process

January 21, 2016

In its ‘What’s New’ section, CMS announced on November 9, 2015 that as part of the Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act), the MSPRP will be modified to include Final Conditional Payment (CP) process functionality by January 1, 2016. This new functionality will permit authorized MSPRP users to notify CMS that a recovery case is 120 days (or less) from an anticipated settlement and request that the recovery case be a part of the Final CP process.

When the Final CP process is requested, any disputes submitted through the MSPRP will be resolved within 11 business days of receipt of the dispute. Once all disputes have been resolved, and the case is within 3 days of settling, the beneficiary or their authorized representative will be able to request a Final Conditional Payment Amount on the MSPRP. Once calculated, this amount will remain the Final Conditional Payment Amount as long as:

The case is settled within 3 calendar days of requesting the Final Conditional Payment Amount, and
Settlement information is submitted through the MSPRP within 30 calendar days of requesting the Final Conditional Payment Amount.

How the NGHP recovery process works today

To understand the value of this announcement to simplify the final demand process, we need to revisit the recent changes in NGHP recovery and the new role of the Commercial Repayment Center (CRC).

Effective October 5, 2015, the CRC assumed responsibility for pursuing recovery directly from the applicable plan. Any recoveries initiated by the Benefits Coordination & Recovery Center (BCRC) prior to the October 2015 transition will continue to be the responsibility of the BCRC. The typical recovery case, where Medicare is pursuing recovery directly from the applicable plan, now involves the following steps:

1. Medicare is notified that the applicable plan has primary responsibility

Medicare may learn of other insurance through a Medicare, Medicaid, and SCHIP Extension Act (MMSEA) Section 111 report or beneficiary self-report. If Medicare is notified that the applicable plan is primary to Medicare, Medicare records are updated with this information.

2. CRC searches Medicare records for claims paid by Medicare

The CRC begins identifying claims that Medicare has paid that are related to the case, based upon details about the type of incident, illness, or injury alleged. The claims search will include claims from the date of incident to the current date. If a termination date for Ongoing Responsibility for Medicals (ORM) has already been reported, the CRC will collect claims through and including the termination date.

3. CRC issues Conditional Payment Notice (CPN) to the applicable plan

The CPN provides conditional payment information. It advises the applicable plan that certain actions must be taken within 30 days of the date on the CPN or the CRC will automatically issue a demand letter. This notice includes a claims listing of all items and services that Medicare has paid that are related to the case. It also explains how to dispute any items and services that are not related to the case. A courtesy copy of the CPN is sent to the beneficiary and beneficiary’s attorney or other representative. The applicable plan’s recovery agent will also receive a copy of the CPN if the recovery agent’s information was submitted on the applicable plan’s MMSEA Section 111 report or the applicable plan has otherwise appointed a recovery agent by submitting a written authorization to the CRC.

Note: If a beneficiary or his or her attorney or other representative reports a no-fault insurance or workers’ compensation situation before the applicable plan submits a Section 111 report, the applicable plan will receive a Conditional Payment Letter (CPL). The CPL provides the same information as a CPN, but there is no specified response timeframe. When this occurs, the applicable plan is encouraged to respond to the CPL to notify the CRC if it does not have ORM and will not be reporting ORM through Section 111 reporting or if the applicable plan would like to dispute relatedness.

4. Applicable plan submits a dispute

The applicable plan has 30 days to challenge the claims included in the CPN. The applicable plan may contact the CRC or use the Medicare Secondary Payer Recovery Portal (MSPRP) to respond to the CPN.

5. CRC issues recovery demand letter advising plan of monies owed to Medicare

The demand letter advises the applicable plan of the amount of money owed to the Medicare program and requests reimbursement within 60 days of the date of the letter. A courtesy copy of the demand letter is sent to the applicable plan’s recovery agent, the beneficiary and the beneficiary’s attorney or other representative. The demand letter includes the following:

The beneficiary’s name and Medicare Health Insurance Claim Number (HICN);
Date of accident/incident;
A claims listing of all related claims paid by Medicare for which Medicare is seeking reimbursement from the applicable plan; and
The total demand amount (amount of money owed) and information on administrative appeal rights.
If the CRC agrees with disputes submitted timely, unrelated claims will be removed from the case before the demand letter is issued. Please note that the demand letter may include related claims that Medicare paid after the CPN was issued. Relatedness disputes on all claims included in the demand letter may be addressed by submitting an appeal.

6. Applicable plan submits an appeal

An applicable plan has 120 days from the date the applicable plan receives the demand letter to file an appeal. Receipt is presumed to be within 5 calendar days absent evidence to the contrary.

7. Applicable plan submits payment

If the CRC receives payment in full, it will issue a letter stating that the specified debt has been resolved. The letter will also note that new cases may be created if the applicable plan maintains ORM or the CRC receives information on additional items or services paid by Medicare during the period of ORM.

Facilitating timely and more accurate final demands

Because the CRC retains the right to create new cases as long as the applicable plan maintains ORM, timely notification of a final settlement is extremely critical to terminate the recovery efforts of the CRC. We applaud the addition of CP process functionality to the MSPRP as a segue to real time information and data exchange, and a more predictable outcome.

With more timely submissions and a published timeline for the final demand, this new extension of the SMART Act will facilitate better accuracy, a better path to closure and fewer last minute surprises…. all good things for those who represent the settlement interests workers’ compensation and liability carriers.