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CMS discusses conditional payment appeal issues on its NGHP Applicable Plans webinar

On September 24th, the Centers for Medicare and Medicaid Services (CMS) and the Commercial Repayment Center (CRC) held a webinar session to address “redetermination” requests as part of the administrative appeals process regarding conditional payment disputes of non-group health plans (NGHP). As part of this 75-minute session, CMS touched on several different topics, including the steps in the administrative appeals process, timelines and other requirements for redeterminations, and what arguments CRC will accept as part of a redetermination request.

The following provides a general overview of the main areas addressed by CMS and the CRC on this webinar:

Administrative appeals process – overview

The CRC began the webinar with a review of the formal administrative appeals process available to primary payers for disputing conditional payment demands. The CRC explained this process is open to appeal “initial determinations,” including CRC demand letters. Of note, the CRC noted primary payer disputes of pre-demand correspondences issued by CMS or its contractors, such as conditional payment letters (CPL) or conditional payment notices (CPN) are not part of the administrative appeals process.

The CRC noted the administrative appeals process consists of five levels as follows:

  1. Redetermination by the CRC;
  2. Reconsideration by a CMS Qualified Independent Contractor (QIC);
  3. Hearing before an Administrative Law Judge (ALJ);
  4. Review by the Departmental Appeals Board’s Medical Appeals Council (MAC); and
  5. Judicial Review in federal court.

The focus of this webinar, as noted above, was on redeterminations (level one), and the panel did not address the appeals process beyond the redetermination level. While a review of each level of appeal is beyond the scope of this article, it is noted the administrative appeals process is outlined more fully at 42 C.F.R. § 405.900, et seq. (Subpart I – Determinations, Redeterminations, Reconsiderations, and Appeals Under Original Medicare Part A and B). 

Adhering to appeal timelines and requirements is critical

Next, the CRC emphasized adherence to established appeal timelines and other related requirements is critical. On this point, the CRC advised redeterminations must be received within 120 days from the date a Medicare demand letter is received by the named debtor, which CRC noted is presumed to be five days after the date of demand.

Additionally, the redetermination request must include required information such as demographic information regarding the Medicare beneficiary, the dates of service under dispute, and an explanation as to why the applicable plan (or their recovery agent) disagrees with the CRC’s initial determination. Further, the CRC noted a Letter of Authority (LOA) from the primary payer must be on file if an appeal is being submitted by an authorized representative on behalf of the debtor. If an LOA is not on file when an appeal is submitted, then one must be submitted simultaneously with the appeal, or else the appeal will be dismissed. The CRC stressed failure to submit a timely appeal or provide the required information is likely to result in an unfavorable redetermination.

Debtors are limited to specific arguments on appeal

According to the CRC, it only accepts redetermination appeals disputing a conditional payment debt's amount or existence. In practice, this stems from primary payer claim information reported though Section 111 reporting, which the CRC relies heavily on for its recovery practices. 

The CRC outlined the specific arguments it will accept as part of a redetermination request as follows:

  • Termination of Ongoing Responsibility for Medicals (ORM) due to benefits exhaustion;
  • Termination of ORM due to settlement or other claim resolution;
  • Benefits denied/revoked by applicable plan;
  • Non-covered services;
  • Unrelated services; and
  • Duplicative primary payment.

In addition to understanding the types of appeals the CRC will accept, the CRC stressed debtors must provide the correct information and documentation required for each argument to maximize the chances of a favorable redetermination.

CMS’s PowerPoint

CMS's PowerPoint for this webinar can be found here.  

Claims considerations

With the steady stream of Medicare conditional payment demands issued by the CRC, primary payers and their authorized representatives need to understand CMS’s administrative appeals process. Particularly the timelines and requirements related to redeterminations which is an important first step of this process, per this webinar. As discussed by the CRC in the webinar, there is a limited timeframe for primary payers to file a redetermination and the CRC is adhering strictly to this requirement. Thus, primary payers must have a process to identify Medicare conditional payment correspondence and ensure Medicare demands are reviewed and addressed to ensure redetermination requests are filed promptly.  

Likewise, it is also important redeterminations contain the required information and supporting documentation to avoid the request being rejected. Given CMS’s strong reliance on data reported via Section 111, this includes reviewing Section 111 reporting to ensure the data is up to date and accurate.     

Please do not hesitate to contact the authors if you have any questions regarding this webinar or conditional payment issues and disputes.

ISO Claims Partners can help reduce conditional payments

ISO Claims Partners is the industry leader in helping primary payers identify, dispute, and resolve conditional payment claims. We can help you address conditional payment claims either on a case by case basis or through our state of the art (and popular) CP Link program, which applies a programmatic and proactive approach to conditional payments driven off Section 111 data. 

Through our experience and expertise, we continue to deliver significant savings for our clients. In 2019, we achieved a 91% average reduction in conditional payment disputes (and 70% of the time, we reduced CMS’s claimed amount to zero) – saving our customers over $59 million. So far, in 2020, we have saved our customers over $37 million from our conditional payment dispute services – with our CP Link program savings of approaching $10 million alone in 2020. 

Learn more about our services and how we can help here.

Sid Wong, J.D.

Sid Wong is the Vice President of Policy at Verisk Casualty. In this capacity Sid monitors and evaluates the changing state of Medicare Secondary Payer compliance to develop impactful solutions to emerging MSP issues and works to ensure that Verisk’s Casualty’s policies, products, and services continue to align with the MSP landscape. He also oversees Verisk Casualty’s policy team, which provides policy and compliance support for all of Verisk Casualty’s clients. During his tenure he has served as Legal Director, Assistant Director of Services, Client Solutions Manager, and MSP Compliance Manager. Sid is a subject matter expert on MSAs, Conditional Payment Recovery, and Section 111 reporting. He collaborates with clients to develop best practices and respond to any compliance or policy questions, whether it’s a case level issue or evaluating a process impacting the larger organization. He regularly presents at industry conferences and provides training for clients.

Prior to joining Verisk, Sid worked for a small general practice firm in New Hampshire where he received his JD from University of New Hampshire Franklin Pierce School of Law. Sid is a member of the MA, NH, and NY bar, the IAIABC, NAMSAP, MARC, and is MSCC certified.

Shawn Johnson, J.D.

Shawn Johnson is legal director, Casualty Solutions at Verisk. You can contact Shawn at

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