Last week representatives from the Commercial Repayment Center (CRC) and Centers for Medicare and Medicaid Services (CMS) Medicare Secondary Payer (MSP) Operations teams hosted a webinar on best practices for conditional payment redetermination requests for Non-Group Health Plan (NGHP) payers.

The presentation included a review of the five levels of the Medicare appeals process, the standard set of requirements applicable to all redetermination requests, and a reminder that only the amount and/or existence of a debt is subject to appeal.

Recommendations were made to include additional documentation, beyond the standard appeal requirements, to support each of the following types of disputes:

  1. Policy Limit Exhaustion – provide a payment ledger to prove proper exhaustion and combine both Med Pay and PIP limits when applicable.
  2. Dates of Service Occurring After Settlement or Other Resolution – provide a copy of the final, signed settlement documents or, if there was no settlement, then offer other documentation to support the termination of the policy.
  3. Denied or Revoked Benefits – provide a copy of the notice of denial or decision sent to the beneficiary, referencing both the date of injury and reason for denial or revocation of benefits.
  4. Non-Covered Services – provide plan or policy documents to demonstrate the scope of allowed coverage, evidence that services were outside the scope of the policy, and  – when applicable – a payment ledger documenting the denial. *Note that the Q&A session expanded upon this discussion to emphasize that the CRC reviewer needs to see a reason why service was denied, either by way of written explanation or a denial code with a key of reasons for denial on a payment ledger.
  5. Unrelated Services – provide written explanation as to why services or diagnoses are unrelated to the beneficiary’s claim with the applicable plan. *Note that the Q&A session reviewed examples of appropriate evidence as including, but not limited to: determinations made by a state board that a service would not be covered; limitations in coverage based upon plan/policy requirements; or other appliable state law such as the UR/IMR process in California. The explanation and documentation must be clearly articulated for the reviewer. 
  6. Duplicate Payments – provide a payment ledger to demonstrate that payment for the date of service being demanded for repayment has already been appropriately paid. This payment may not be made to the provider after receiving a Demand.

Following the planned portion of the presentation, the CRC and CMS team fielded questions from the industry, during which a variety of topics were covered. A few key take-aways were as follows:

  • If a demand is made based upon Section 111 reporting data that is incorrect or out of date, then the Responsible Reporting Entity (RRE) should concurrently:
  • appeal the demand; and
  • update the Section 111 report to be accurate.

If the correction is only made with the CRC and not at the root level (Section 111 Reporting), then potential remains for additional recovery cases to generate with the same incorrect information. Incorrectly reported ICD-10 codes are a valid basis for dispute.

  • Listeners were reminded of an RRE’s option to report off-cycle, when they wish to expedite their report of Ongoing Responsibility for Medicals (ORM) termination prior to their next assigned reporting period.
  • Following a successful appeal, why are additional cases sometimes opened, causing the RRE to appeal the same issue repeatedly? Representatives explained that this is most likely to happen in pre-demand status and because new dates of service or claims are identified which were previously excluded. The CRC stated that they are reviewing this process internally for possible enhancements to be made.
  • What constitutes good cause for missing an appeal deadline? Good cause for a late appeal is intended to be a remedy from a situation in which it was impossible to respond to a demand before the expiration of the applicable time frame. Examples included: natural disasters, COVID-19 mailroom closures, or other scenarios that have prevented access to mail.
  • Have a scenario in which you wish to pay a conditional payment when ORM remains open? The CRC may be reached by email at [email protected] or by fax at (844) 315-7627 to request payment instructions.

We offer assistance with conditional payments, lien resolutions, as well as establishing proper Medicare compliance protocols. For more information on these services, please visit our website here, or contact our team at [email protected].