Revisions to WCMSA Reference Guide

Posted August 2, 2017

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CMS’ re-review process has undergone recent changes. The change was formallyannounced through a revised Workers’ Compensation Medicare Set-Aside Portal (WCMSAP) User Guide. The new re-review option became available and effective as of July 31, 2017. In order to exercise the re-review option, the following thresholds must be met:

• The MSA must have been originally submitted between one and four years from the date the re-review is submitted (thereby eliminating very recently approved cases as eligible for this re-review process)
• The re-review request cannot have had a previous request for an Amended Review: and
• The new allocation must result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount.

The Amended Review will allow for changes in care to be accounted for by CMS for cases which have not settled.

Within the revised WCMSA reference guide, CMS also:

• Further defined expectations of Hearings on the Merits (Section 4.1.4);
• Updated requirements for Spinal Cord Stimulator pricing with CPT coding (Section 9.4.5);
• Corrected BCRC contact information
• Expanded state-specific statute guidelines (Section 9.4.5)
• Specified total settlement calculations guidelines (Section 10.5.3)
• Added ICD-10 examples to the Sample Cover Letter found in the guide;
• Clarified jurisdictional verification (Section 9.4.4, Step 5);
• Clarified change of submitter requirements (Sections 9.0, 10.2, ands 19.4);
• Added required resubmission requirements (Section 16.1);
• Updated administration recommendations (Section 17.1);
• Added MyMedicare.gov link (Section 17.6); and
• Updated Off-Label Medication requirements (Section 9.4.6.2).

Furthermore, within the guide, CMS announced that it will now recognize state specific statutes addressing limitation on future treatment. This will have an important impact for those jurisdictions which have a jurisdictional statutory cap limiting funding a MSA over a claimant’s entire lifetime. This is the first limitation of its kind to be honored by CMS.