Author: Michelle Allan, Principal

 

Already off to a hot year in WCMSA updates, CMS kicks off Q2 with another round of new information for the Medicare Secondary Payer community. Workers’ Compensation Medicare Set-Aside Reference Guide Version 4.3 published April 7, 2025 serves up the awaited language associated with the Amended Review timeframe elimination, as well as a Change of Submitter of Record process and a Notice of Settlement Received letter template. A summary of the changes are as follows:

 

 Section 16.3: Amended Review

  • Eligibility: Allows a one-time request for re-review if CMS has issued a conditional approval/approved amount, the case has not settled, and projected care changes result in at least a 10% or $10,000 difference in the approved amount.
  • Submission Requirements: New cover letter, all medical documentation since the last submission, most recent six months of pharmacy records, consent to release information, and summary of expected future care.
  • Justification: Identify care already provided or no longer required, and add new required care items.
  • Update: One year wait period eliminated.

 

Section 19.4: Change of Submitter

  • Process: If the submitter changes, the new submitter must provide a signed statement from the previous submitter authorizing the change. This ensures continuity and proper handling of the WCMSA proposal.
  • Requirements: The new submitter must comply with all CMS guidelines and provide necessary documentation to support the change.
  • Update: A change of submitter as a standalone change does not warrant Amended Review.

 

Appendix 5: Notice of Settlement Received Letter

  • Purpose: This letter is sent to notify the Beneficiary that CMS has received the settlement information. It includes details about the settlement and instructions for any further actions required.
  • Content: The letter outlines the settlement terms, the WCMSA amount, and administration information.
  • Update: New letter supports WCMSA data field inclusion in Section 111 reporting, providing the Beneficiary with information relevant to obligations and coordination of benefits, including a Case Control Number, if an MSA was not previously submitted to CMS for approval.

 

For more detailed information, you can refer to the WCMSA Reference Guide version 4.3 Please contact info@allankoba.com to discuss these changes.