Tag Archives: CMS

CMS Issues Section 111 NGHP User Guide Version 6.0

The new Section 111 NGHP User Guide 6.0 (Guide) was issued by CMS on October 5, 2020 and contains several updates as noted below. Chapter III, Section 4.6 of the Guide, CMS has specified what items should be included when calculating the Total Payment Obligation to Claimant (TPOC).  CMS notes that the “TPOC amount includes, […]

New WCMSA Reference Guide 3.2 Issued by CMS

On October 5, 2020, CMS issued a new WCMSA Reference Guide (Guide) version 3.2.  Changes to the Guide include defining what major medical centers the Workers’ Compensation Review Contractors (WCRC) utilize for pricing surgical interventions in WCMSAs.  A copy of the new Guide can be found here. Specifically, CMS added a new Appendix 7 to […]

CMS Provides Webinar: Section 111 Non-Group Health Plan (NGHP)

August 17, 2020 by Patrick Czuprynski  On 8/13/2020, CMS provided a webinar and PowerPoint presentation to highlight and refresh stakeholders regarding certain aspects of Section 111 reporting and the recommendations outlined in the MMSEA Section 111 User Guide. It is important to understand that CMS is using the carrier/self-insured (or their TPA) claims system reporting […]

CMS Issues New WCMSA Reference Guide 3.1

May 19, 2020 by Bridget Smith, JD CMS has released a new Workers’ Compensation Medicare Set-Aside Reference Guide, Version 3.1, May 11, 2020, COBR-Q2-2020-v3.1 a link to which can be found here:  https://www.cms.gov/files/document/wcmsa-reference-guide-version-31.pdf  This version of the Guide contained the new reference to  the CDC life table 2017 that CMS has been utilizing for the […]

Confusion, Conjecture and Clarification: The New WCMSA Reference Guide

With the issuance of updated Workers’ Compensation Medicare Set-Aside Reference Guide version 2.9 (Guide), there has some speculation and even confusion as to what is really new and what is an elaboration of old policies and procedures.  Examples listed for off-label drug usage to new bullets added regarding the submission process, all of which begs […]

doctor speaking to a patient

Success in the CMS Re-Review Process

Pursuant to Section 16.0 of the Workers’ Compensation Medicare Set Aside (WCMSA) Reference Guide, Version 2.8, October 1, 2018, COBR-Q4-2018-v2.8, CMS will conduct a Re-Review of a prior WCMSA determination in certain circumstances.  Specifically, CMS will complete this process in cases involving a mistake in the allocation; mathematical error; or when there is missing documentation […]

nurse taking the blood pressure of an elderly woman

THE WHITTLING AWAY OF CMS OFF-LABEL USAGE ARGUMENTS IN THE WCMSA

With the transition to the new Workers’ Compensation Review Contractor (WCRC), the industry is seeing many changes in the Workers’ Compensation Medicare Set-Aside (WCMSA) review process. One of the biggest changes has been the shift from excluding Lyrica from the WCMSA when it is being prescribed for an off-label use to the inclusion of this […]

CMS WCRC Posts New Phone Number!

For CMS WCRC inquiries or help, call their new number—855.280.3550. Press 1: For English Press 2: For Spanish then Press 2: To enter the CMS Case Control Number (no letters) for customer service Press 3: To reach customer service directly