CMS Insurer NGHP Recovery

Medicare recovers payments it made that should have been the responsibility of liability insurers (including self-insured entities), no-fault insurers or workers’ compensation entities. These entities are often collectively referred to as applicable plans or Non-Group Health Plans (NGHPs). Effective October 5, 2015, the Commercial Repayment Center (CRC) assumed responsibility for pursuing recovery directly from the applicable plan. Any recoveries initiated by the Benefits Coordination & Recovery Center (BCRC) prior to the October 2015 transition will continue to be the responsibility of the BCRC. For information on when to contact the CRC and the BCRC for assistance with Medicare recovery, click the Non-Group Health Plan Recovery link. This link can also be used to access additional information and downloads pertaining to NGHP Recovery.

The typical recovery case, where Medicare is pursuing recovery directly from the applicable plan, involves the following steps:

1. Medicare is notified that the applicable plan has primary responsibility

Medicare may learn of other insurance through a Medicare, Medicaid, and SCHIP Extension Act (MMSEA) Section 111 report or beneficiary self-report. If Medicare is notified that the applicable plan is primary to Medicare, Medicare records are updated with this information.

2. CRC searches Medicare records for claims paid by Medicare based upon the information reported

The CRC begins identifying claims that Medicare has paid that are related to the case, based upon details about the type of incident, illness, or injury alleged. The claims search will include claims from the date of incident to the current date. If a termination date for Ongoing Responsibility for Medicals (ORM) has already been reported, the CRC will collect claims through and including the termination date.

3. CRC issues Conditional Payment Notice (CPN) to the applicable plan

The CPN provides conditional payment information. It advises the applicable plan that certain actions must be taken within 30 days of the date on the CPN or the CRC will automatically issue a demand letter. This notice includes a claims listing of all items and services that Medicare has paid that are related to the case. It also explains how to dispute any items and services that are not related to the case. A courtesy copy of the CPN is sent to the beneficiary and beneficiary’s attorney or other representative. The applicable plan’s recovery agent will also receive a copy of the CPN if the recovery agent’s information was submitted on the applicable plan’s MMSEA Section 111 report or the applicable plan has otherwise appointed a recovery agent by submitting a written authorization to the CRC. Please see the Recovery Agent Authorization Model Language in the Downloads section at the bottom of this page.

Note: If a beneficiary or his or her attorney or other representative reports a no-fault insurance or workers’ compensation situation before the applicable plan submits a Section 111 report, the applicable plan will receive a Conditional Payment Letter (CPL). The CPL provides the same information as a CPN, but there is no specified response timeframe. When this occurs, the applicable plan is encouraged to respond to the CPL to notify the CRC if it does not have ORM and will not be reporting ORM through Section 111 reporting or if the applicable plan would like to dispute relatedness.

4. Applicable plan submits a dispute

The applicable plan has 30 days to challenge the claims included in the CPN. The applicable plan may contact the CRC or use the Medicare Secondary Payer Recovery Portal (MSPRP) to respond to the CPN. Click the MSPRP link for details on how to access the MSPRP.

Note: When settling a liability case or a workers’ compensation case, the applicable plan may be able to initiate the Final Conditional Payment process on the MSPRP. This process can only be initiated if:

• The settlement is pending, and
• No outstanding Ongoing Responsibility for Medicals (ORM) exists.

Initiating this process will close the applicable plan’s case and transition the debt to the beneficiary. The applicable plan will not be able to work the beneficiary-debtor case or receive copies of any recovery-related correspondence related to the new beneficiary-debtor case until they obtain and submit an authorization signed by the beneficiary. Please see the MSPRP User Guide for additional information on the Final Conditional Payment process. The User Guide is available under the ‘Reference Material’ menu option of the MSPRP application.

5. CRC issues a recovery demand letter advising the applicable plan of the amount of money owed to Medicare

The demand letter advises the applicable plan of the amount of money owed to the Medicare program and requests reimbursement within 60 days of the date of the letter. A courtesy copy of the demand letter is sent to the applicable plan’s recovery agent, the beneficiary and the beneficiary’s attorney or other representative. The demand letter includes the following:

• The beneficiary’s name and Medicare Number;
• Date of accident/incident;
• A claims listing of all related claims paid by Medicare for which Medicare is seeking reimbursement from the applicable plan; and
• The total demand amount (amount of money owed) and information on administrative appeal rights.

If the CRC agrees with disputes submitted timely, unrelated claims will be removed from the case before the demand letter is issued. Please note that the demand letter may include related claims that Medicare paid after the CPN was issued. Relatedness disputes on all claims included in the demand letter may be addressed by submitting an appeal.

6. Applicable plan submits an appeal

An applicable plan has 120 days from the date the applicable plan receives the demand letter to file an appeal. Receipt is presumed to be within 5 calendar days absent evidence to the contrary. Please see the Applicable Plan Appeals Presentation available in the Downloads section at the bottom of this page.

7. Applicable plan submits payment

If the CRC receives payment in full, it will issue a letter stating that the specified debt has been resolved. The letter will also note that new cases may be created if the applicable plan maintains ORM or the CRC receives information on additional items or services paid by Medicare during the period of ORM.

Note: Interest on the debt accrues from date of the demand letter and, if the debt is not resolved within 60 days, is assessed for each 30 day period the debt remains unresolved. Payment is applied to interest first and principal second. Interest continues to accrue on the outstanding principal portion of the debt. If an applicable plan requests an appeal, the debt will not be referred to the Department of Treasury while the appeal is being processed, but interest will continue to accrue. The applicable plan may choose to pay the demand amount while appealing the overpayment in order to avoid the accrual and assessment of interest. (An appropriate refund is made if the appeal is favorable to the applicable plan.)