CMS Establishes Appeal Rights for Applicable Plans
CMS Establishes Appeal Rights for Applicable Plans including Liability Insurance (Self-Insurance), No Fault Insurance, and Worker’s Compensation Laws. On May 27, 2015, the CMS May 5, 2015 webinar presentation regarding establishing appeal rights for Applicable Plans became available in the Downloads section of the CMS Insurer Services What’s New page of CMS.gov.
For any recovery demand letter issued after April 28, 2015, the Applicable Plan will be able to appeal Medicare’s recovery claim. Only the Applicable Plan is party to the appeal process. The beneficiary will receive a notice that the applicable plan has filed an appeal, but the beneficiary is not a party and will not participate in the appeal. (see references 80 FR 10611 CMS-6055-F; 42 CFR 405.924(b)(16); 42 CFR 405.906; 42 CFR 405.947; 42 CFR 405.910)
Additional applicable references:
• Appeal regulations for claim-based appeals, including denials and MSP recovery claims: Subpart I of 42 CFR Part 405. See the 405.900’s and the code references following.
• Final Rule for applicable plan appeals: 80 FR 10611, February 27, 2015.
• “APPEAL RIGHTS FOR APPLICBLE PLANS”: April 22, 2015 outreach document for insurers and workers’ compensation entities, available on Insurer Services section of cms.gov.
• “Appeals Process for Insurers and Workers’ Compensation Entities and Required Notice to Medicare Beneficiaries”: April 23, 2015 outreach document for Medicare beneficiaries on the Beneficiary Services section of cms.gov. This document includes an example of the beneficiary notice required by 42 CFR 405.947.