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CRC Commences Applicable Plan Recovery Process

Starting October 5, 2015, the Commercial Repayment Center (CRC) began identifying and recovering Medicare’s conditional payments for all new recovery cases where Centers for Medicare and Medicaid Services (CMS) pursues recovery directly from an applicable plan as the identified debtor.

The specific workload to be transitioned only involves recovery cases where CMS is pursuing recovery from an applicable plan as the identified debtor. For CRC recoveries, an “Applicable Plan” means: 

  • Liability insurance (including self-insurance), 
  • No-fault insurance, or
  • A Workers’ compensation law or plan.

(See 42 USC 1395y(b)(8) and 42 CFR 405.902)

CMS pursues recovery directly from an applicable plan as the identified debtor when an applicable plan reports that it has ongoing responsibility for medicals or otherwise notifies CMS of its primary payment responsibility (when this responsibility is not in dispute).  The underlying process will remain the same with CRC as it has in the past.  The Benefits Coordination and Recovery Center (BCRC) will continue to pursue all cases where it has initiated recovery activities prior to October 5, 2015.  Additonally, the BCRC will continue to recover Medicare’s conditional payment for all cases where the beneficiary is the identified debtor, before and after October 5, 2015. 

All other current BCRC activities, such as MMSEA Section 111 Mandatory Insurer Reporting, will remain unchanged.   For reporting, an applicable plan must report that it has primary payment responsibility to the BCRC, including reporting Ongoing Responsibility for Medicals (ORM) through MMSEA Section 111 reporting, or a beneficiary/ beneficiary’s representative reports that an applicable plan may have primary payment responsibility.

Related to conditional payments, the CRC identifies any conditional payments made by Medicare. A Conditional Payment Notice (CPN) is issued to the applicable plan (unless the only information source is the beneficiary self-report, in which case a Conditional Payment Letter (CPL) is issued).

For all disputes, an applicable plan has one opportunity to dispute medical claims identified on the CPN before a formal request for repayment, or demand, is issued.

For all demands made by Medicare, if one or more conditional payments remain following the dispute response period, a demand letter, or initial determination, will be issued. This is the CRC’s first request for payment.

For all appeals, applicable plans may appeal the amount or existence of the debt, in part or in full. Applicable plans will have one opportunity to initiate the formal appeal process. 

If a plan fails to respond to the demand, interest accrues from the date of the demand letter and is assessed if the debt is not resolved within 60 days. If the debt continues to be unresolved, the CRC will issue an Intent to Refer (ITR) letter informing the applicable plan of next steps should the debt remain unpaid.  If any portion of the debt remains delinquent 180 days from the date of the demand letter, the CRC will initiate the process to refer the debt to the Department of the Treasury for additional collection activities.

For more information about the process, please feel free to call us about your particular circumstances.  Additonally, click here for a copy of the transition presentation from CMS >>

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