CMS has issued a Commercial Repayment Center Non-Group Health Plan Applicable Plan Appeal Guide (Appeal Guide) in the Download section on the Insurer NGHP Recovery page on CMS.gov. A copy of the Appeal Guide can be found here. The Appeal Guide outlines the steps in the appeals process; appeal requirements; necessary authorizations; what is and what is not subject to appeal; and examples. These examples include filing appeals in situations where there is termination of Ongoing Responsibility for Medicals (ORM) due to benefit exhaustion; termination of ORM as a result of claim resolution/settlement; situations where benefits have been denied or revoked; and when the applicable plan asserts services were not covered, are unrelated, or involve duplicate payments made for the same service. This guidance highlights the importance of Section 111 Reporting accuracy especially in light of the proposed rule regarding Civil Monetary Penalties (CMPs). The proposed rule notes that CMPs would be issued if Section 111 Reporting data is inconsistent with the information provided for conditional lien inquiries and disputes.
For further information or questions regarding this posting or for any of your MSP compliance needs, please contact our Settlement Consultant team at: [email protected]