CMS seeks to review and make a decision regarding proposed Workers' Compensation (WC) settlements within 45 to 60 days, from the time that all necessary/required documentation has been submitted.

Who to Contact

If you are contacting Medicare for the first time in order to report a WC occurrence please contact the Coordination of Benefits (COB) Contractor at (800) 999-1118.

In the event that there are questions regarding your Workers' Compensation Medicare Set-aside Arrangement (WCMSA) submission, please follow the following procedure:

If you have not received an acknowledgement letter regarding your WCMSA submission, please contact the Coordination of Benefits (COB) Contractor at (800) 999-1118.

If you have received an acknowledgement letter and have not yet received a decision from CMS regarding your WCMSA submission, please contact the Workers' Compensation Review Contractor at (301) 575-0160.

If you have received a CMS decision with regard to the WCMSA submission and have a question about the case, please contact the appropriate regional office.  Each Regional office is assigned WCMSA cases based upon the state where the WC claim is pending.  For example, if your WC claim is pending in Alabama, then your regional office is Atlanta.  Please click on the Download link below for the States in Each Region.

WCMSA Appeal Rights

 (Ref: 7/11/05 Memo Q12)

There are no appeal rights if a claimant or submitter disagrees with the WCMSA amount that CMS has determined protects Medicare's interests.  However, claimants and submitters have several other options available to them. First, a claimant or submitter may always contact the RO that issued the CMS determination for a clarification. Also, if the claimant or submitter believes that a CMS determination contains obvious mistakes, such as mathematical errors or failure to recognize that medical records already submitted show that a surgery that CMS priced has already occurred, then the claimant or submitter should contact the RO that issued the CMS determination for a correction of the errors.

Where the claimant or submitter believes that CMS has misinterpreted the evidence or disagrees with the CMS determination for some other reason, there are two choices available. If the claimant or submitter believes that there is additional evidence not previously considered by CMS that would warrant a change in the CMS determination, the claimant or submitter may resubmit the case with the additional evidence and request a reevaluation.

The re-evaluation request should be clearly marked as such, submitted to the Coordination of Benefits Contractor (COBC), P.O. Box 33849, Detroit, Michigan 48232-5849, and must be accompanied by additional evidence not available at the time of the original submission. It will then be considered a new submission and shall be processed in order of receipt.

If the additional information does not convince the RO to approve the set-aside arrangement, and the parties proceed to settle the case despite the ROs objections, then Medicare will not recognize the settlement. Medicare will exclude its payments for the medical expenses related to the injury or illness until such time as WC settlement funds expended for services otherwise reimbursable by Medicare exhaust the entire settlement.

Although a claimant has no formal appeal rights with respect to the WCMSA process, beneficiaries do have appeal rights with respect to specific denied claims. If CMS denies a submitted claim for a service on the basis that CMS determined the WCMSA amount has not been exhausted, the beneficiary may appeal that specific claim denial through the administrative appeal process.

Judicial Decisions

(Ref: 4/21/03 Memo Q5)

Medicare will generally honor judicial decisions issued after a hearing on the merits of a WC case by a court of competent jurisdiction. If a court or other adjudicator of the merits specifically designates funds to a portion of a settlement that is not related to medical services (e.g., lost wages), then Medicare will accept that designation.

However, a distinction must be made where a court or other adjudicator is only approving a settlement that incorporates the parties' settlement agreements. Medicare cannot accept the terms of the settlement as to an allocation of funds of any type if the settlement does not adequately address Medicare's interests. If Medicare's interests are not reasonably considered, Medicare will refuse to pay for services related to the Workers' Compensation (WC) injury (and otherwise reimbursable by Medicare) until such expenses have exhausted the amount of the entire WC settlement. Medicare will also assert a recovery claim, if appropriate.

In addition, CMS will separately evaluate any special situations regarding WC cases, when State WC non-compensable medical services are at issue.  A copy of the applicable statute supporting the special state situation should be forwarded to the COBC, Attn: WCMSA Proposal, P.O. Box 33849, Detroit, Michigan 48232-5849, as part of the case file.

Indemnity Payments and CMS Review of a WCMSA

(Ref: 7/11/05 Memo Q4)

There is a way to avoid the continuation of indemnity payments while awaiting a CMS determination on a proposed WCMSA. To avoid this situation, CMS recommends that the claimant (or the claimant's representative) close out the indemnity portion of the settlement and leave the settlement of medical expenses open pending a determination by CMS on the proposed WCMSA. In determining the review thresholds, the total settlement amount, including indemnity and medicals, shall be used.

Note that the computation of the total settlement amount includes, but is not limited to, wages, attorney fees, all future medical expenses, and repayment of any Medicare conditional payments, and that payout totals for all annuities to fund the above expenses should be used rather than cost or present values of any annuities. Also note that any previously settled portion of the WC claim must be included in computing the total settlement amount.

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Page Last Modified: 12/11/2007 9:45:37 AM
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