Highlights of CMS’ August 25, 2015 Webinar on the Commercial Repayment Center’s (CRC) New Role in the Non-Group Health Plan (NGHP) Recovery Process

CMS announced in its webinar that the transition of the Non-Group Health Plan (NGHP) recovery process to the Commercial Repayment Center (CRC) will be completed by October 5, 2015. This transition of the recovery workload from the Benefits Coordination and Recovery Contractor (BCRC) will only impact new conditional payment recovery actions directed towards a liability insurer (including self-insurance), no-fault insurer, or a workers’ compensation entity, or otherwise known as Applicable Plans. Pending actions against these entities will continue to be managed by the BCRC. Similarly, all recovery actions against Medicare beneficiaries and data collection activity will remain the responsibility of the BCRC.

CMS speakers Pickholtz and Wright stressed the need for parties to carefully review all conditional payment recovery correspondence in order to identify the proper contractor handling the action. Although a Medicare beneficiary may receive a courtesy copy of a direct recovery claim against an Applicable Plan, any claim initiated as of October 5, 2015 will be managed by the CRC. Correspondence to the CRC should be directed to: Commercial Repayment Center-NGHP, PO Box 93965, Cleveland, OH 44101.

The Conditional Payment Letter (CPL) and Conditional Payment Notice (CPN) were discussed during the webinar. Although both the CPL and CPN identify the amount of the current conditional payment, provide a Statement of Reimbursement (SOR) and describe the manner for disputing the charges, they also have significant differences that should be noted by the parties. The first difference pertains to the event that triggers the issuance of the document. The CPL is generally issued when a beneficiary self reports that an Applicable Plan has primary payment responsibility for an incident, while a CPN is generally issued when an Applicable Plan reports under Section 111 that it has Ongoing Responsibility for Medicals (ORM) or a responsibility for the claim as a primary payer.

The key difference however between the CPL and CPN documents pertains to the manner for disputing the identified conditional payments. Conditional payments noted in a CPL may be disputed at any time, while conditional payments noted in a CPN must be disputed within 30 days of the date of the CPN. Applicable plans will have one opportunity to file a dispute in response to a CPN. If the CRC agrees with the dispute, it will remove the claims from the SOR. If it does not agree with the dispute, the conditional payments will be reflected in the demand letter.

If an Applicable Plan fails to reply to the CPN in a timely manner, a demand letter will be issued. Although Applicable Plans now have appeal rights for recovery demand letters issued to the Plans on or after April 28, 2015, failure to respond to the CPN or CPL prior to the demand letter “locks” the Applicable Plan in as the identified debtor. In light of this, Applicable Plans should make sure that they implement a procedure for the timely review of CPNs and CPLs. To ensure receipt of conditional payment recovery correspondence, the Applicable Plans should keep their Section 111 reporting information updated. Additional details regarding the formal appeal process may be found in CMS’ “Applicable Plan” Appeals download.

CMS will be providing additional webinars on the transition of the NGHP recovery process to the CRC. We will keep you advised of further developments as they arise.

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