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CMS Issues a Final Rule on Conditional Payment Appeals

On February 27, 2015, CMS issued a final rule in the Federal Register that implements a required provision of the Strengthening Medicare and Repaying Taxpayers Act (the SMART Act). This provision establishes a formal right of appeals process for applicable plans regarding conditional payments.

This new appeals process applies to initial CMS determinations issued on or after April 28, 2015 where CMS is pursuing conditional payment recovery from applicable plans. Instead of adopting a new process, this new rule adopts the same multilevel appeals process for applicable plans that is currently allowed for conditional payment recovery claims from beneficiaries.

This multilevel appeals process for applicable plans includes these steps:

  • A redetermination by the contractor issuing the recovery demand
  • A reconsideration by a Qualified Independent Contractor (QIC)
  • An Administrative Law Judge (ALJ) hearing.
  • A review by the Departmental Appeals Board’s (DAB) Medical Appeals Council (MAC)
  • An eventual judicial review

For further analysis see the notice in the February 27, 2015 Federal Register.

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