New Re-Review Guidelines added to the WCMSA Reference Guide Version 3.8
Last Updated: 14 Nov 2022
Author: Ciara F. Koba, Esq., CMSP
On November 14, 2022, CMS released version 3.8 of the WCMSA Reference Guide. If you attended the Medicare Secondary Payer Network 2022 Annual Conference (The National Medicare Secondary Payer Network) in September, you may have been anxiously anticipating the release of this updated guide with the hope that clarification on re-review requests would be provided as CMS agency officials discussed these changes would be coming soon. Christmas has come early as CMS has provided clarification on re-review requests and made some changes. Specifically, CMS has added a new category entitled "Submission Error". Submitters may not submit re-review requests where the documentation originally submitted contained errors that resulted in a discrepancy in pricing of no less than $2,500. This new category and specific guidelines surrounding the same can be found in Section 16.1 and 16.2 of the WCMSA Reference Guide.
Section 16.1 and 16.2 provide (emphasis added):
When CMS does not believe that a proposed set-aside adequately protects Medicare’s interests, and thus makes a determination of a different amount than originally proposed, there is no formal appeals process. However, there are several other options available. First, the claimant may provide the WCRC with additional documentation in order to justify the original proposal amount. If the additional information does not convince the WCRC to change the originally submitted WCMSA amount and the parties proceed to settle the case despite the lack of change, then Medicare will not recognize the settlement. Medicare will exclude its payments for the medical expenses related to the injury or illness until WC settlement funds expended for services otherwise reimbursable by Medicare use up the entire settlement. Thereafter, when Medicare denies a particular beneficiary’s claim, the beneficiary may appeal that particular claim denial through Medicare's regular administrative appeals process. Information on applicable appeal rights is provided at the time of each claim denial as part of the explanation of benefits.
A request for re-review may be submitted based one of the following:
- Mathematical Error: Where the appropriately authorized submitter or claimant disagrees with CMS’ decision because CMS’ determination contains obvious mistakes (e.g., a mathematical error or failure to recognize medical records already submitted showing a surgery, priced by CMS, that has already occurred), or
- Missing Documentation: Where the submitter or claimant disagrees with CMS’ decision because the submitter has additional evidence, not previously considered by CMS, which was dated prior to the submission date of the original proposal and which warrants a change in CMS’ determination. Disagreement surrounding the inclusion or exclusion of specific treatments or medications does not meet the definition of a mathematical error. Re-Review requests based upon failure to properly review already submitted records must include only the specific documentation referenced as a basis for the request. Should no change be made upon response to a re-review request (i.e., no error was identified), additional requests to re-review the same error will not be entertained.
- Submission Error: Where an error exists in the documentation provided for a submission that leads to a change in pricing of no less than $2500.00, a re-review request may be made by submitting updated documents free of errors that caused the original review outcome. Amended documents must come from the originators with appropriate notation to identify that the error was corrected, along with the date of correction and no less than hand-written “wet” signature of the correcting individual. Note: This submission option is only available for approvals from September 1, 2022 forward. Examples include, but may not be limited to: medical records with incorrect patient identifying information or rated ages where the rated-age assessor provided incorrect information in the rated-age document.
16.2 Re-Review Limitations
- Note: The following re-review limitations are only available for approvals from September 1, 2022 forward. Re-review shall be limited to no more than one request by type.
- Disagreement surrounding the inclusion or exclusion of specific treatments or medications does not meet the definition of a mathematical error.
- Re-Review requests based upon failure to properly review already submitted records must include only the specific documentation referenced as a basis for the request.
If you have questions about these changes or would like to explore requesting re-review on a previously submitted case, please contact firstname.lastname@example.org and a member of our team would be happy to assist.
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