In follow-up to their September 2020 webinar on Non-Group Health Plan (NGHP) appeals, yesterday the Centers for Medicare & Medicaid Services (CMS) converted the slides from that presentation, publishing them as: Commercial Repayment Center Non-Group Health Plan Applicable Plan Appeal Guide, located under the downloads section of the Insurer NGHP Recovery CMS page.

There were some minor edits from the original presentation. Most notably, the addition of one additional appropriate basis for appeal: termination of Ongoing Responsibility for Medicals (ORM) due to other policy terms. With this addition, CMS’ complete list of situations in which the amount of and/or existence of a debt may be appealed is as follows:

  • Termination of Ongoing Responsibility for Medicals (ORM) Due to Benefits Exhaustion
  • Termination of ORM Due to Settlement or Other Claim Resolution
  • Benefits Denied/Revoked by Applicable Plan
  • Non-Covered Services
  • Unrelated Services
  • Duplicate Primary Payment
  • Termination of ORM Due to Other Policy Terms

You can review MEDVAL’s recap of the webinar, in our prior post: Best Practices for Conditional Payment Appeals and More Questions Answered by the CRC and CMS MSP Operations Team.