New CMS claims payment process begins January 1, 2016

December 31, 2015 / 1 min read

On December 24, 2015, the Centers for Medicare and Medicaid Services (CMS) issued a reminder that its claims payment process for ongoing responsibility for medicals (ORM) reporting will change on January 1, 2016.

As part of this new process, CMS claims processing contractors will use the ORM information reported to determine whether Medicare is able to make payments for claims. The agency is “strongly” encouraging insurers and workers' compensation entities to accurately report ICD-9 or ICD-10 codes, as its contractors will use this information to pay accordingly.

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This new CMS notice reiterates information announced in a July 2015 alert, which announced that effective October 5, 2015, CMS would use the Commercial Repayment Center (CRC) to pursue certain conditional payment recovery claims against nongroup health plans. The alert further stated that, effective January 1, 2016, the agency would add an “additional limitation” to Medicare claims payments in situations where ORM is reported.

Most significantly, as part of the upcoming process change, CMS may now pursue actual reimbursement of conditional payment claims in ORM situations prior to claim settlement. Claims payers may start to receive conditional payment notices (CPNs) seeking reimbursement where they have ORM, even though the claim has not settled (and may never settle). This represents a significant change in CMS policy, in that up until now the agency has typically only pursued actual reimbursement upon claim settlement.

It is important that all claims payers (especially those handling lines where ORM is applicable) note these changes and adjust their best practices accordingly.

A copy of CMS’s December 24, 2015 notice can be obtained here.

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