New Process for Resolution of Conditional Payments Prior to Settlement for Payers with Ongoing Responsibility for Medical is Effective October 5, 2015

Rafael Gonzalez, Esq.
Vice President, Strategic Solutions, Helios


On September 17, 2015, the Centers for Medicare and Medicaid Services (CMS) held its second webinar regarding Non-Group Health Plan (NGHP) new workload to the Commercial Repayment Center (CRC). As they did during their first webinar held on August 25, 2015, CMS again reminded listeners that the specific workload to be transitioned to the CRC only involves recovery cases where CMS is pursuing recovery from an applicable plan, liability insurance (including self-insurance), no-fault insurance, or a workers’ compensation law or plan, as the identified debtor.

CMS again reiterated that “starting October 5, 2015, the CRC will identify and recover Medicare’s conditional payments for all new recovery cases where CMS pursues recovery directly from an applicable plan as the identified debtor. CMS will pursue recovery directly from an applicable plan as the identified debtor when an applicable plan reports that it has ongoing responsibility for medicals (ORM) or otherwise notifies CMS of its primary payment responsibility.”

As was also previously indicated, “the Benefits Coordination and Recovery Center (BCRC) will continue to pursue all cases where it has initiated recovery activities prior to October 5, 2015. In addition, the BCRC will continue to recover Medicare’s conditional payments 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 (MIR), will remain unchanged.”

The New CRC Conditional Payment Recovery Process

During the webinar, CMS again reviewed the new CRC recovery process for Applicable Plans with ORM as the identified debtor. The new CRC conditional payment recovery process is as follows:

  • Reporting
    “An applicable plan reports that it has primary payment responsibility to the BCRC, including reporting ORM through MMSEA Section 111 reporting, or a beneficiary/beneficiary’s representative reports that an applicable plan may have primary payment responsibility.”
  • Conditional Payment Notice
    “The CRC will identify conditional payments related to the claim made by Medicare. A Conditional Payment Notice (CPN) will then be issued to the applicable plan.” CMS made it clear during the webinar that “if the applicable plan’s primary payment responsibility does not terminate and the CRC identifies additional conditional payments, further CPNs (and demand letters) may be issued for these additional conditional payments.”
  • Dispute
    “Applicable plans will have one opportunity to dispute medical claims identified on the CPN before a formal request for repayment, or demand, is issued. APs will have 30 days from the date of the CPN to dispute whether the payments included in the CPN are related to the claim. If the AP does not respond within 30 days, CRC will assume such charges are related to the claim and forward a demand letter.”
  • Demand
    “If one or more conditional payments remain following the dispute response period, a demand letter, or initial determination, is issued. This is the CRC’s first request for payment.” The AP will have 60 days within which to make payment without being charged any interest. Payments made after such 60 days will be charged interest from the date of the demand letter.
  • Appeal
    “Applicable plans may appeal the amount or existence of the debt, in part or in full.” Applicable plans have an opportunity to initiate the formal appeal process by requesting redetermination. Formal appeals process available thereafter also includes a request for reconsideration, request for a hearing, request for review, and federal court action.
  • Failure to Respond
    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, including referral to the Department of Treasury (DOT) for collections.”
  • Referral to Treasury
    “If any portion of the debt remains delinquent more than 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.”

Conditional Payment Notices and Conditional Payment Letters by the CRC

During the webinar, CMS indicated that “the CRC will issue a Conditional Payment Notice or a Conditional Payment Letter (CPL) when Medicare is notified that an applicable plan has or may have primary payment responsibility for an illness, incident, or injury and Medicare has made conditional payments. The CPL
will be issued instead of the CPN
when a beneficiary reports a pending case where an applicable plan may have primary payment responsibility for an illness, incident, or injury and
the MSP occurrence was not otherwise reported by the applicable plan (through MMSEA Section 111 reporting or by other means). Otherwise, a CPN
will be issued. The CPN or CPL will be issued to the applicable plan, with a courtesy copy mailed to the beneficiary and any authorized representatives.”

Differences between Conditional Payment Notice and Conditional Payment Letter

During the webinar, CMS indicated that “the Conditional Payment Notice includes conditional payment information on a Statement of Reimbursement (SOR) noting items or services Medicare has paid conditionally. The CPN will also explain how to dispute any items and/or services included on the SOR. Should the applicable plan wish to dispute any of the payments, the dispute must be filed within 30 days of the CPN date. The CPN is automatically followed by the demand letter if no dispute is received by the response due date provided on the CPN.”

“The Conditional Payment Letter includes the same information as the CPN. The CPL however does not have a specific response due date and is not automatically followed by the demand letter.”

“The CRC Statement of Reimbursement will be similar to the BCRC Payment Summary Form (PSF). It will be provided as an enclosure with the CPL, CPN, and demand letter. It will provide the recipient with a listing of Part A and Part B medical claims conditionally paid by Medicare and identified in the current recovery case. It will include information on medical claim conditional payment amount, diagnostic information, and the total conditional payment amount.”

Disputing the Conditional Payment Notice or Conditional Payment Letter

During the webinar CMS indicated “Applicable Plans may dispute the CPL or CPN. Applicable plans will have one opportunity to dispute a CPN before a demand letter is issued. The dispute must be submitted by the response due date to allow review before the demand letter is issued. The CRC will review and evaluate the dispute (if received by the due date), removing payments from the Statement of Reimbursement, if appropriate. Any conditional payment that remains part of the recovery case will be included in the demand letter figures, as well as any additional conditional payment information that has been received and added to the recovery case.”

During the webinar, CMS also indicated that “when challenging CRC’s inclusion of any medical payment, disputes should include an explanation and documentation, such as a payment ledger. Payment ledgers should include date of service, payee name, billed amount, amount paid to provider, physician, or other supplier, date processed and/or date payment was made.”

The Demand Letter and Formal Appeal Rights

“If no dispute is received following a CPN, or a dispute is received and the recovery case still contains one or more medical claims, a demand letter will be issued to the applicable plan. The demand letter will include basic information regarding the recovery case, an explanation of how to appeal any items and/or services that the debtor believes should be removed from the recovery case. An updated Statement of Reimbursement will be enclosed with the demand letter.”

As per federal regulations approved earlier this year, “when CMS issues a demand letter dated on or after April 28, 2015 directly to the applicable plan, the applicable plan has formal administrative appeal rights, which includes a request for redetermination, request for reconsideration, request for a hearing, request for review, and federal court review.”

Communicating with the CRC

During the webinar CMS reminded listeners that “all recovery correspondence will be mailed to the address provided for the applicable plan. As a result, it is the responsibility of the applicable plan to provide accurate recovery address information through MMSEA Section 111 reporting. If the applicable plan wishes to have another individual or entity involved with post-demand correspondence (including filing an appeal) to resolve the matter on the plan’s behalf, the CRC must have a written authorization on file.”

CMS also indicated that “once the demand is issued, recovery agents will need to submit written authorization to continue working with the CRC. An applicable plan must submit a separate authorization for each CRC Recovery ID # to ensure recovery agents are included on correspondence post-demand.”


As previously indicated in several or our blogs over the last few weeks, if you have not already put together a plan to handle CMS’ request for reimbursement of conditional payments from the Commercial Recovery Center on files where the payer has ongoing responsibility for medical care associated with a claim, it is imperative you act as soon as possible. With CRC starting this new process on October 5, 2015, the time is now to make sure you have a program in place that:

  • communicates the appropriate ICD-9 or ICD-10 code to CMS through your Mandatory Insurer Reporting platform;
  • provides your vendor has the appropriate authority to communicate with the CRC;
  • allows all of the appropriate and necessary parties to receive the Conditional Payment Notices;
  • has a systematic process in place to look at each CPN to determine whether any payments made that CMS is seeking reimbursement are related to the claim;
  • contains a programmatic system to dispute such payments within the allotted 30 day period;
  • includes a specifically designed tool for receipt and action on the Demand Letter, which includes assistance with payment of the outstanding debt due to CMS within 60 days of the Demand Letter, or if still disagree with CRC’s determination, the start of the formal appeals process by requesting redetermination;
  • also allows for the ability to request reconsideration, request a hearing, and request review;
  • provides multiple reminders to the right individuals within your organization of any outstanding debt, especially those older than 180 days that will be referred to the Department of Treasury for collection;
  • has an established process and standard procedures to deal with Treasury and its debt collection contractors;
  • will provide ongoing reports to the appropriate individuals of status update on all claims where the CRC or BCRC has sought reimbursement of such conditional payments.

As one of the oldest, largest, and most respected MSP vendors in the industry, entrusted to serve a large volume of liability insurance (including self-insurance), no-fault, and workers compensation plans, Helios Settlement Solutions has built a programmatic process that will systematically go through each of the components necessary to successfully handle the CRC conditional payment process. Should you be interested in speaking with us about this or any of our other Medicare Secondary Payer compliance products and services, please contact us at 888.672.7674, or at

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