CMS Releases NGHP Appeals Reference Guide 1.0

by B. Smith

The Centers for Medicare & Medicaid Services (CMS) recently released the first Non-Group Health Plan (NGHP) Applicable Plan Appeals Reference Guide, Version 1.0 (Guide) dated April 27, 2023, the purpose of which is to provide applicable plans (i.e., insurers, self-insured entities, liability insurers and workers’ compensation insurers) and their authorized representatives with guidance when submitting appeals for conditional payment recovery claims. The Guide provides information on appealing conditional payment demand letters, gives an overview of the appeals process, and lists the types of appeals as well as the documentation needed to support each type of appeal. Below is a summary of some of the pertinent information from the Guide. For a full review, you can access the Guide on the Insurer NGHP Recovery page at

Section 2.0: Appealing Medicare’s Demand

CMS reminds debtors that interest can accrue on demand letters if the debt is not resolved within 60 days. If a plan requests an appeal at any level, the debt will not be referred to the Department of Treasury. However, CMS also notes that if the debt is sent to the Department of Treasury, it will be recalled while the appeal is pending. Department of Treasury referrals have been an issue plaguing primary payers for years.

Additionally, CMS provides a broad overview of the administrative appeals process including the Initial Determination, Redetermination, Reconsideration, Hearing, Review by Medicare Appeals Council, and Judicial Review. They warn that correspondence from CMS is always presumed to be received within five days of receipt and late appeals at any level may only be accepted with good cause.

Section 2.1: How to Submit Redetermination Requests

CMS notes that requests may be submitted through the Medicare Secondary Payer Recovery Portal (MSPRP) or submitted on paper by mailing or faxing documents.

Significantly, CMS also notes the following:

By law, insurers are required to ensure the information reported to Medicare as mandated by
Section 111 of the Medicare, Medicaid, and SCHIP Extension Act (MMSEA) of 2007
(commonly referred to as “Section 111 reporting”) is accurate and up to date.

This is a very important note, and a subtle reminder, that inaccurate reporting could lead to future Civil Money Penalties.

Section 2.2: Standard Appeal Documentation Requirements

CMS indicates that a request for a redetermination must be made within 120 days from the date of the demand letter and outlines the elements necessary for the cover letter.

Section 2.3: Authorization/Letter of Authority Requirements

CMS reviews the requirements needed for having another party assist primary payers with resolving a conditional lien demand. CMS states that appeal requests from any entity that is not identified as the applicable plan/primary payer, or their authorized representative, will be dismissed and a request to vacate the dismissal will be resolved within the appeal timeframe. CMS also warns that if a representative is late in submitting the required authorization, the applicable plan/primary debtor risks having the appeal dismissed.

Section 3.0: NHGP Applicable Plan Appeals

In this Section, CMS identifies some common appeal types as follows:

    • Termination of Ongoing Responsibility for Medicals (ORM) Due to Benefits Exhaustion
    • Termination of ORM Due to Settlement or Other Claim Resolution
    • Termination of ORM Due to Other Policy Terms
    • Benefits Denied or Revoked by the Applicable Plan
    • Non-Covered Services
    • Unrelated Services
    • Duplicate Primary Payment

Each sub-section of 3.0 then reviews the documentation needed for the various appeal levels.

Below are some of additional notes from CMS on each stage of the process:

    • Payments to physicians, providers, suppliers, or beneficiaries made after receiving Medicare’s demand letter do not excuse the applicable plan in lieu of reimbursing Medicare.
    • The applicable plan should ensure any information reported through Section 111 reporting is updated as soon as possible if ORM has terminated.
    • If a workers’ compensation or no-fault claim is denied by the applicable plan in its entirety, or benefits were revoked effective upon a specific date, the applicable plan should ensure any information reported through Section 111 is updated or deleted immediately.
    • The applicable plan or authorized representative may not make primary payment to the provider, supplier, or beneficiary after receiving a Medicare demand letter in lieu of paying the Medicare demand.

Section 4.0 of the Guide titled, “Additional NGHP Resources,” includes links to several other helpful resources. The document then concludes with a four-section Appendix, which includes sample letters for almost all situations outlined in the Guide along with a detailed glossary of acronyms.

Key Takeaways

Although most of the content in the Guide is a reiteration of CMS practices and procedures, it serves as a good resource for primary plans and recovery agents. It is worthy to note that CMS has placed an emphasis on proper Section 111 Reporting throughout the Guide. After all, Section 111 Reporting impacts all conditional lien recoveries. If ORM, ORM Termination, Total Payment Obligation to Claimant (TPOC) Date, TPOC Amounts, and ICD Coding is reported incorrectly, the primary plan may be impacted by increasing conditional lien exposure. The Medicare beneficiary may also be impacted if payment for medical is denied due to incorrect reporting data.

This concern is further heightened by the fact that CMS will not identify if you are reporting the wrong dates, amounts, injuries etc.  CMS only advises of technical errors. This is one reason to consider an outside audit of your reporting process to review these elements as compared to actual claim information.  A review of a sample of claims can help identify potential issues now which may impact your conditional payment exposure and potential future penalties.

Although CMS also referenced the ability to assert a “good cause” defense of untimely appeals, there are various arguments that can be made even when primary payers have missed appeal deadlines and paid lien amounts. The request to reopen these claims is an invaluable tool in certain cases and can help primary payers recoup thousands of dollars in lien amounts that should not have been paid, but, due to appeal deadlines being missed or failure to properly dispute the lien amount, were paid. IMPAXX has saved our customers millions of dollars in lien disputes through the reopen process. We routinely conduct reopen assessments for our customers to determine if they may be able to recoup amounts already paid for conditional liens.

If you have questions about the newly published Non-Group Health Plan (NGHP) Applicable Plan Appeals Reference Guide, are looking for more information on conditional payment recoveries, or wish to learn more about the reopen process and our Section 111 audit program, please contact our Settlement Consultant Team at [email protected].