Expanded Re-Review Process for MSAs Among Changes Announced in the WCMSA Portal User Guide Update


On July 10, 2017, the Centers for Medicare and Medicaid Services (CMS) released updates to its user guide for the Workers’ Compensation Medicare Set-Aside Portal (WCMSAP). You may find a copy of the updated version (version 5.1) here. Below is a summary of the changes, and information on how these changes may impact your claims.

What changes did CMS make?

  1. CMS made it easier for beneficiaries to access their cases by adding two new pages, a Case Listing page and a Case Documentation page. These pages allow beneficiaries to view case information and associated PDF documents. Additionally, links to these pages were added to the beneficiary’s MyMedicare account.
  2. In anticipation of Medicare Beneficiary Identifiers (MBIs) replacing Health Insurance Claim Numbers (HICNs), CMS renamed the HICN fields to Medicare ID fields. This was required as part of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. Note: CMS will begin issuing updated Medicare cards with the MBI in early 2018. Here is a link to our earlier post on the change to MBIs.
  3. CMS updated its login banner to comply with security and federal privacy controls regarding the use of social media and networking sites.
  4. CMS expanded the WCMSA re-review process “to accommodate situations where projected care for a case has changed so much that the new proposed settlement amount differs from the Medicare approved amount by 10% or $10,000 (whichever is greater). See below for specific details.
  5. And, to accommodate submitters who wish to add documentation to a case that has been closed for more than one year, CMS established additional requirements that now require full resubmission of the case and the associated documentation.

What is the Re-Review process for outdated WCMSAs?

  • The process is called Amended Review.
  • It is available only one time per case.
  • Parties may not request another re-review if the request for the Amended Review is denied (even if the case was denied because it was not eligible at the time of the Amended Review request).
  • The WCMSA must have been originally submitted between 1 and 4 years from the current date.
  • There cannot have been a previous request for an Amended Review
  • The anticipated change in the MSA must result in a 10% or $10,000 change (whichever is greater) from CMS’ previously approved amount.
  • The new proposed MSA amount can be greater than or less than the previously approved MSA amount, so long as the difference is at least 10% or $10,000 (whichever is greater).
  • Parties must provide updated medical or prescription records to support the changes.
  • When the process is complete, and an updated amount is approved, parties will receive an approval letter.

Have any of the other changes impacted WCMSA submissions?

Yes, in two important ways.

  • First, not mentioned above is the new requirement to provide a copy of a ruling or draft/final settlement documents in order to upload a new WCMSA submission to the portal for review. ExamWorks Clinical Solutions worked very quickly to implement updated handling procedures to satisfy this requirement on the files in progress and for all files on a go-forward basis. As always our Development Team will work with impacted clients to mitigate the impact of these changes.
  • Secondly, there is impact on cases where CMS has closed the matter and it has remained closed for over one year. Often, these are situations where perhaps the parties received a development request letter from CMS to produce additional records or other information related to the claim, and for whatever reason the parties were not able to comply in a timely fashion. In the past, parties would respond to the development letter upon securing the requested documentation no matter the date of the development request. Going forward, once a year has passed from the case closure letter provided by CMS, parties will need to complete a “Required Resubmission,” along with the development items, in order for CMS to process the WCMSA. The required resubmission may in fact require parties to obtain updated case records and documents as the guide indicates this submission must include “ALL case documents from the past two years.”

As the industry leader in Medicare and Medicaid Secondary Payer Compliance, ExamWorks Clinical Solutions has hit the ground running after these announced changes. We are truly your partner every step of the way. We are already working with clients on the Amended Review process and, as mentioned above, our Submissions and Development Teams have already taken action to ensure submissions and development items are being accepted into the portal. We will continue to follow any announcements from CMS on this important topic. Should you have any questions about this announcement or CMS’ changes to the WCMSAP user guide, please contact your ExamWorks representative.