Once COBC receives this notice, it in turn notifies another contactor, the Medicare Secondary Payer Recovery Contractor (MSPRC). The MSPRC then issues a Rights and Responsibilities Letter (RRL) advising the parties of Medicare’s potential interests. Thereafter, the MSPRC will issue a Conditional Payment Letter (CPL) within 65 days of the date of the RRL (in practice this timeline can be longer than 65 days).
The CPL contains Medicare’s claimed conditional payment amount and provides a corresponding listing of the claimed charges. The CPL must be examined for accuracy and a request should be made to the MSPRC to remove any inappropriate claims. It is often necessary to request updated CPLs as the claim matures to ensure that the most current conditional payment information is obtained. Under current CMS policy, the parties are generally unable to obtain Medicare’s “final demand” until after the claim is settled and the executed settlement document is forwarded to the MSPRC.[fn4]
2. This article provides only a general overview of how the Query Process system operates. A detailed examination of the technical aspects of the Query Process s (e.g. required software, file types, etc.) is beyond the scope of this article. To review this information see CMS’ NGHP User Guide (December 16, 2011, Version 3.3), Chapters 13 and 15.5.
3. CMS states that the query process “is to be used only for Section 111 reporting purposes” and refers the RRE to the Section 111 Data Use Agreement for restrictions on the use of the data exchanged for Section 111 purposes. See, CMS’ NGHP User Guide (December 16, 2011, Version 3.3), Chapters 13.1 and 16.
4. As an exception to the above process, CMS will issue a Conditional Payment Notice (CPN), in lieu of a CPL, in situations where (a) the MSPRC is notified of a settlement, judgment, award or other payment through Section 111 reporting rather than from the beneficiary or their representative and (b) the MSPRC has been alerted to a settlement, judgment award, or other payment by the beneficiary or their representative before the usual CPL has been issued.
On a related note, some RREs are reporting that they have received CPLs which they believe were triggered from their filing of a Section 111 ORM report (on-going responsibility for medicals). To the extent these reports are accurate this would represent a change from CMS’ current process, and may signal an eventual coordination between Section 111 reporting and CMS’ larger efforts at benefit coordination. In the author’s view, further investigation into these interesting reports is in order. As part of this investigation, an important fact to ascertain would be whether the RRE, in addition to filing a Section 111 ORM report, had also reported the claim to the COBC. If so, the issue for determination would then become whether it was the Section 111 filing or the COBC report that triggered release of the CPL.
To learn more about CMS’ processes to obtain conditional payment information, the reader may wish to review the website www.msprc.info.
5. CMS defines “total settlement amount” as follows: Total settlement amount includes, but is not limited to, wages, attorney fees, all future medical expenses (including prescription drugs) and repayment of any Medicare conditional payments. Payout totals for all annuities to fund the above expenses should be used rather than cost or present value of any annuities. Also note that any previously settled portion of the WC claim must be included in computing the total settlement. Gerald Walters, CMS Memorandum to All Regional Administrators, April 25, 2006.
6. Thomas L. Grissom, CMS Memorandum to All Regional Administrators, April 22, 2003.
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