CMS Issues Updated WCMSA Reference Guide, Changes Re-Review Process
CMS recently released Version 3.8 of the WCMSA Reference Guide providing additional criteria and limitations for the re-review process. The changes will only apply to CMS determinations issued on or after September 1, 2022.
The new Reference Guide provides in Section 16.1 that when there is a “submission error,” a re-review request may be submitted subject to the following criteria:
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.
Prior versions of the Reference Guide only provided for a re-review request when there is a mathematical error or missing documentation (i.e., additional evidence not previously considered by CMS dated prior to the submission).
The Reference Guide includes a new Section 16.2 limiting re-review requests to one request based on the type of re-review request (mathematical error, missing documentation, and submission error). Previously, any number of re-review requests court potentially be submitted. The new Section 16.2 provides as follows:
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.
The new Reference Guide is available at https://www.cms.gov/files/document/wcmsa-reference-guide-version-38.pdf.
