CMS Issues Final Rule re: Conditional Payment Appeals for Applicable Plans



On February 27, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a Final Rule related to appeal rights being granted to Applicable Plans pursuant to Section 201 of the SMART Act. The SMART Act amended the Medicare Secondary Payer (MSP) Act in 2013 in several ways. One way was to grant Applicable Plans a right to appeal final determinations from CMS when CMS pursued the Applicable Plan for reimbursement. Applicable plan means liability insurance (including self-insurance), no-fault insurance, or a workers' compensation law or plan.

In short, CMS intends to provide Applicable Plans the same appeal rights as it currently provides Medicare beneficiaries. Those rights include the ability to access a multi-level process including 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) Medicare Appeals Council (MAC), and eventual judicial review once the beneficiary has standing to pursue such action. With very minor changes to the Proposed Rule it released on December 27, 2014, CMS will grant Applicable Plans a right to appeal when CMS pursues the Applicable Plan for recovery. This Final Rule will be effective 60 days from today or Tuesday, April 28.

Garretson Resolution Group (GRG) continues to track these changes in order to provide our clients with the best means to minimize or extinguish associated reimbursement exposure under the MSP Act. Stay tuned for a more substantive client alert coming shortly from us about how Applicable Plans should review and change their MSP compliance protocols in light of this announcement. For questions about what this means for you or your clients, please call John Cattie at 704-594-1778 or email him at

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