Three Updates from Medicare as We Enter Q4


By Marty Cassavoy, Vice President Medicare Secondary Payer Compliance

October 1st marks the start of a new quarter and the issuance of three updates covering all aspects of Medicare Secondary Payer compliance.  Two updates involve minor changes to Medicare’s User Guides, and the other incorporates additional functionality for the conditional payment portal.  Here’s a short summary of the updates, beginning with the most useful:

MSPR Portal Upgrade

The Medicare Secondary Payer Recovery Portal rolled out an important upgrade that will make the third- party authorization process swifter.  Under the prior process, third parties such as ExamWorks could utilize the portal to upload letters of authority and proofs of representation, but there was a delay in having those authorizations approved.  While the delay was generally short (less than three days), it was a bit inconvenient for an agent who would have to return to the portal a few days later to interact on behalf of its client.  

The upgrade to the portal allows authorizations to be instantly verified.  After completing the required fields and uploading written proof of authorization to the portal, the user attests that the information is true and complete to the best of their knowledge.  Once the authorization is uploaded, the process is complete and the user can utilize immediately the portal without limitations.

We are fans of this upgrade.  The last six months witnessed improvements in the portal.  Earlier this year the portal was updated to allow authorized users to download electronic conditional payment letters and track the history of a conditional payment claim.  This upgrade provides no fancy bells and whistles, but it should make filings go more smoothly.  So far, so good.

WCMSA Reference Guide Update: SSNRI and Zip Codes

On October 1st Medicare released version 2.8 of the WCMSA Reference Guide.  CMS’ made two updates to its comprehensive policy and technical document for Medicare’s Set-Aside review program:

  • CMS announced changes to comply with the ongoing Social Security Number Removal Initiative (SSNRI).  These changes, which ExamWorks has covered several times, will result in the provision of new Medicare numbers for every Medicare beneficiary no later than April 2019.  To comply with these changes CMS will provide claimant’s new Medicare numbers in correspondence provided in response to request for approval of a Medicare Set Asides.   It has also re-labeled the information to reflect these changes.
  • CMS also modified some tables illustrating which calculation method to utilize depending upon the claim’s workers’ compensation jurisdiction.  The updated tables make no major substantive policy changes, but they do clarify what can be a confusing hierarchy for the uninitiated.  The bottom line is that the if the claimant does not reside in the same state in which the workers’ compensation claim is filed, then the fee schedule is based on a hierarchy from the zip code of the employer through the zip code of the employer’s counsel.  An additional table outlines the appropriate fee schedule to use in situations involving Longshore cases, cases where no fee schedule exists and cases filed with the U.S. Department of Labor Office of Workers’ Compensation Programs.

These relatively minor updates make no substantive changes, but they are worthy of notice.

NGHP User Guide Update: Personnel, RREs and ICD-10 Codes

On October 1st CMS also provided an update to the Section 111 NGHP User Guide.  The Section 111 User Guide is key policy and technical document for the Section 111 reporting process.  The User Guide includes five chapters.  The October 1st update included changes to four of the chapters, as follows:

  • In chapters 1, 2 and 4, CMS updated the escalation process for contacting CMS representatives to reflect that Angel Pagan has replaced Jeremy Farquhar as the EDI Department Director.
  • In chapter 4, under the section “Claim Input File Do’s and Don’ts,” CMS reminded RREs to submit policy number uniformly and in the same format.  In chapter 5, CMS reiterated this guidance and noted it was to ensure that updates are properly applied to conditional payment recovery cases.
  • In chapter 5, CMS made a modification for “Y” ICD-10 codes.  In addition, CMS announced updates to the list of excluded ICD-9 and ICD-10 codes for 2019.  Beginning in 2019, claims containing these codes will be rejected.  ExamWorks Clinical Solutions edits for these codes and makes the necessary updates to its system logic to capture and exclude these codes, as applicable.

The first week of the quarter is busy with these changes.  The updates to the MSPR Portal are welcome.  Our MIR Service team will be reviewing the updated ICD-9 and ICD-10 codes to make any required changes.  Should you have any questions, please do not hesitate to contact Marty Cassavoy at 781-517-8085 or