Medicare Conditional Payment Claim Appeal User Guide Published


CMS and the Commercial Repayment Center recently published a User Guide for non-group health plan conditional payment claim appeals. The information presented in the User Guide mirrors topics discussed in their recent webinar concerning conditional payment claim appeals. The Guide is available at https://www.cms.gov/files/document/commercial-repayment-center-non-group-health-plan-applicable-plan-appeal-guide.pdf.


Conditional payment claim appeals may be based on one or more of the issues noted below.

1. Termination of ORM Due to Benefits Exhaustion in No-Fault Cases A cover letter should be submitted with a copy of the payment ledger showing the dates of service, total amount of claims billed, total amount paid to each provider, the date payment was processed/issued, and the name of the payment recipient. The total amount of payments must equal the policy limit amount reported under Section 111. It should be noted if reimbursement was issued to the beneficiary for out of pocket expenses, but otherwise CMS and CRC explained that they will not recognize an argument that the policy limits were paid to the beneficiary as a basis for appeal since Medicare still has the right to recover from a primary payer when funds are paid to the beneficiary.

2. Termination of ORM Due to Settlement or Other Claim Resolution A cover letter should be submitted with a copy of the signed settlement documents showing the effective date of the settlement. If ORM has terminated due to a termination or lapse of the insurance policy, supporting documentation should be submitted on letterhead outlining the effective dates of the policy. 3. Benefits Denied/Revoked Documentation should be provided that clearly demonstrates that benefits were denied/revoked. A copy of the decision letter to the beneficiary should be provided explaining the reasons for denial. If a denied claim was reported under Section 111 in error, it should be deleted through Section 111. 4. Non-Covered Services CMS and CRC will consider an argument that the services at issue were not covered by the applicable plan in cases when the beneficiary did not submit required documentation to the applicable plan, when the services or service provider was not approved or licensed by the state or state law, the services required prior authorization, or the specific services are not covered by the applicable plan. Documentation must be provided from the plan or policy showing what is not covered and what requirements exist for services to be covered. If payment was denied, a copy of the payment ledger should be provided showing that payment was denied along with a denial code on the payment ledger or an explanation on the payment ledger for why the services were not covered. 5. Unrelated Services The applicable plan or the plan’s agent should provide a copy of the payment summary form with notes explaining why the charges are unrelated or a signed letter on letterhead explaining the same. 6. Duplicate Primary Payment This situation applies when Medicare and the applicable plan have both issued payment for the same services. A copy of the payment ledger must be provided showing the dates of service, total amount of claims billed, amount paid to provider, date each payment was made, and the name of each payment recipient. Payment should not be issued to the provider after receiving Medicare’s demand letter. There is a 45 day time frame for CRC to process conditional payment claim appeals. CRC will look at the diagnosis codes reported under Section 111 in determining which charges appear related. The time frame for appealing an initial demand is 120 days. Before claims are referred to the Department of Treasury for collection, the identified debtor will receive a notice of intent to refer the claims to the Department of Treasury for collection, which provides a 60 day time frame for a response. The intent to refer letter is often sent close to the 120 day appeal deadline, and the 60 day deadline listed in intent to refer letters can create confusion about the deadline for appeals. Despite the 60 day time frame listed in intent to refer letters, CMS and CRC explained that the appeal deadline is 120 days. Under federal regulations, the 120 day deadline starts on the date of receipt of the demand and there is a presumption that the demand was received within 5 days of when it was issued. If claims are referred to the Department of Treasury, the debt will be sent back to CRC if the validity of the debt is in question. The identified debtor or the debtor’s agent must show good cause for submitting a late appeal. CRC will seek recovery based on information reported under Section 111. If appropriate, applicable plans should update information reported under Section 111 when submitting an appeal. Applicable plans and their agents can request a Conditional Payment Notice prior to ORM termination by contacting CRC at crccprequests@performantcorp.com or by fax at 844-315-7627. If you have any questions about any of these issues or need assistance with conditional payment claims, please do not hesitate to contact us.

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