NQBP Alert! CMS’ Proposed expansion of the WCMSA Re-Review Process
On February 11, 2014, CMS released a proposed expansion of the WCMSA re-review process with comment period open until March 31, 2014.
Currently CMS’ re-review process is limited and can be used if one of the following has occurred:
- CMS’ determination contains obvious mistakes (e.g. mathematical error or failure to recognize medical records already submitted showing a surgery, priced by CMS, that has already occurred
- You believe you have additional evidence, not previously considered by CMS, which was dated prior to the submission date of the original proposal and which warrants a change in CMS’ determination
The proposed expansion would expand on the process for a broader array of reasons.
Original WCMSA was approved within the last 180 days, the case has not settled; no prior re-review request has been submitted for this WCMSA; and, the review requests a change to the approved amount of 10% or $10,000 (whichever is more) for any of the following reasons:
- Submitter disagrees with how the medical records were interpreted
- Medical records dated prior to the submission date were mistakenly omitted
- Items or services priced in the approved set-aside amount are no longer needed or there is a change in the beneficiary’s treatment plan
- A recommended drug should not be used because it may be harmful to the beneficiary
- Dispute of items priced for an unrelated body part
- Dispute of the rated age used to calculate life expectancy
Click here to read the full proposed expansion.