Flagship Services Group Blog

Early Takeaways from CRC NGHP Applicable Plan Appeals Webinar

Sep 29, 2020 7:11:58 PM / by Robert J. Finley

On September 24, 2020, CMS hosted a webinar for Commercial Repayment Center Non-Group Health Plan Applicable Plan appeals covering standard appeal requirements, authorization letters, and six common situations which are subject to appeal. CMS provides these instructions and reminders for the Applicable Plan or its Authorized Recovery Agent to use during the redetermination (“appeal”) phase after any initial Medicare demand dispute is denied. This is required information for Applicable Plans and their Authorized Recovery Agents to stay current and updated on CMS’ administrative appeal processes.


The important takeaway here is that you can greatly increase success on appeal through timely and complete submission of all documentation, routine follow through on those appeals, and, in the first instance, recording accurate data in the Section 111 claim input file. Implementing best practices for anticipating and responding to Medicare demands will most likely reduce the frequency and length on these claims and, ultimately, avoid Department of Treasury collection referrals.


Plot your course. Be proactive. Create winning compliance strategies in line with best claims handling procedures and business judgment rule


Standard Appeal Requirements

A request for redetermination must be submitted no later than 120 days from the date of receipt of Medicare’s demand letter (assumed to be five days after the demand date, unless there is evidence to the contrary). Depending upon the basis of the appeal, there may be specific information and documentation that must be provided to sustain the appeal request. Note that this information must be provided on company letterhead or otherwise indicate its source.

Generally, the following documentation must be submitted by the Applicable Plan (or authorized recovery agent) for any level of appeal along with an explanation why the demand (also known as the initial determination) is incorrect:

  • Name of the party or, or the authorized representative of the party
  • Name of Beneficiary
  • Medicare Number
  • Date of Incident (DOI)
  • Summary of injuries from the incident specific service(s) and/or item(s) for which a redetermination is being requested
  • Specific date of service(s), and
  • An explanation of why the applicable plan or authorized recovery agent disagrees with the Medicare’s initial determination

Reminder: Authorization/Letter of Authority Requirement

An authorization (typically the Letter of Authority, or LOA) must either already be on file or submitted simultaneously with the redetermination request if the identified debtor wishes to be represented by another party in resolving the demand. Appeal requests from any entity who is either not the identified debtor (the Applicable Plan) or an authorized representative will be dismissed. An authorization may be submitted with a request to vacate the dismissal but delays in receiving an appeal request from a duly authorized entity means that the identified debtor runs the risk of their appeal request then being dismissed for not being submitted timely. Be sure to review model language for authorizations and include a cover letter or other identifying information to link your authorization to a recovery case.

What is and is not Subject to Appeal

By regulation, the Applicable Plan may only appeal the amount and/or the existence of the debt. Any appeal with any other basis will be dismissed.

Appeals of the amount and/or existence of the debt may be based upon one or more of the following situations

  • Termination of Ongoing Responsibility for Medicals (ORM) due to benefits exhaustion
  • Termination of ORM due to settlement or other claim resolution
  • Benefits Denied/Revoked by Applicable Plan
  • Non-covered Services
  • Unrelated Services
  • Duplicate Primary Payment

Termination of Ongoing Responsibility for Medicals (ORM) due to Benefits Exhaustion


The Applicable Plan asserts it does not have primary payment responsibility for some or all the dates of services included in the demand on the basis that the no-fault policy limit has been reached and benefits exhausted as outlined in the policy or plan.

Documents Needed:

  • Cover letter that contains all required as outlined above.
  • Payment ledger that demonstrates benefits were appropriately exhausted that accumulates to the reported policy limit (appropriate exhaustion means payment for specific services rendered by physician or facility). The documentation must include
    • Date(s) of service
    • Total amount of claim(s) billed
    • Amount paid to Provider
    • Date processed/payment was made
    • Name of recipient of processed claim or payment (note if reimbursement was made to beneficiary for out of pocket payment)




  • The Applicable Plan may not make primary payment to the physician, provider, or other supplier or beneficiary after receiving a Medicare demand latter in lieu of paying the Medicare demand.
  • The CRC may request a declaration page that documents the plan’s no-fault policy limits if the policy limit asserted in the appeal differs from the reported policy limit.
  • Applicable plans must combine Med Pay and PIP limits for a given policy and ORM must be maintained until both the PIP and the Med Pay benefits are exhausted.

Termination of ORM due to Settlement or Other Claim Resolution


            The Applicable Plan asserts it does not have primary payment responsibility for some of all the dates of service included in the demand letter as ORM has terminated due to a settlement, judgment, or award, or for another reason (for example, treatment ended in the absence of requirements such as lifetime medicals). Generally, Medicare claims with dates of service between ORM effective and termination dates are the responsibility of the CRC to recover from the Applicable Plans.

Documentation Needed:

  • Cover letter that contains all required elements as previously outlined.
  • A copy of the complete settlement documentation should be provided complete with signatures and effective dates

Please Note:

  • If ORM has terminated due to benefits exhausted, then follow the guidance for ORM termination due to benefits exhaustion.
  • If ORM has terminated due to policy being terminated or lapsed, then provide supporting documentation that outlines policy effective dates on the Applicable Plan’s or authorized recovery agent’s letterhead.

Benefits Denied/Revoked


When the Applicable Plan or authorized recovery agent asserts that a Worker’s Compensation or No-Fault claim was denied or that benefits were revoked based on incident incurring health costs occurred during (or after) a violation of coverage policy, or State or Federal Law

Documentation Needed:

  • Cover letter that contains all required elements as outlined above.
  • Proper documentation must clearly demonstrate and document the benefits for the claim were denied/revoked for the DOI in question
    • Copy of decision letter from the applicable plan to the beneficiary, specific to the DOI, indicating the reason why the claim was denied, or benefits were revoked.

Non-Covered Services


An Applicable Plan may use this appeal type when

  • Beneficiary did not submit the required documentation ot the applicable plan needed to process or pay claims for the DOI
  • Service(s) or service provider was not approved or licensed by the state or state law
  • Service(s) required prior-authorization
  • Service(s) were not covered by the plan

Documentation Needed:

  • Cover letter that contains all required elements as outlined above.
  • Proper documentation specific to the DOI in question, that must clearly demonstrate that the services were not covered. Copy of plan documents or policy, indicating what services are not covered or what requirements exist for the policy
    • Date(s) of service
    • Total amount of claim(s) billed
    • Provider Name
    • Date processed/payment was denied
    • Denial code/reason stating services were not covered

Unrelated Services


This appeal can be used by the applicable plan and/or authorized recovery agent when one or more specific claims for service(s) or treatment are for a condition unrelated to the accident, date of loss, or incident.

Documentation Needed:

  • Cover letter that contains all the elements as outlined above.
  • Copy of Medicare’s annotated payment summary form or an attestation on an Applicable Plan’s or authorized recovery agent’s letterhead outlining why specific service(s)/diagnosis code(s) are determined to be unrelated.

Duplicate Primary Payment


When Medicare and an Applicable Plan both makes primary payment for the same date of service(s) listed on a Medicare demand, the Applicable Plan or authorized recovery agent may provide proof of their primary payment as an appeal.

Documentation Needed:

  • Cover letter that contains all required information
  • Proper documentation, such as a payment ledger form, that must clearly outline the below information
    • Date(s) of service
    • Total amount of claim(s) billed
    • Amount previously paid to Provider
    • Date processed/payment was made
    • Name of recipient of processed claim or payment

Reminder: The Applicable Plan or authorized recovery agent may not make primary payment to the Provider/Supplier/Beneficiary after receiving Medicare demand letter in lieu of paying the Medicare demand.

Disclaimer: This publication is provided for informational purposes only.  It is not intended to constitute, and shall not be construed as, the rendering of legal, accounting, or business advice or opinion or professional services of any type.  Nothing herein constitutes the views of the firm or its clients or the endorsement of any particular case, principle, or proposition.  The contents of this publication should not be viewed as a substitute for the guidance, advice, or recommendations of a retained professional


Flagship Services Group is the premier Medicare and Medicaid compliance services provider to the property & casualty insurance industry. Our focus and expertise have been the Medicare and Medicaid compliance needs of P&C self-insureds, insurance companies, and third-party administrators. We specialize in P&C mandatory reporting, conditional payment resolution, and set aside allocations. Whether auto, liability, no-fault, or work comp claims, we have assembled the expertise, experience and resources to deliver unparalleled MSP compliance and cost savings results to the P&C industry. To find out more about Flagship, our team, and our customized solutions, please visit us at www.flagshipservicesgroup.com. To speak with us about any of our P&C MSP compliance products and services, you may also contact us at 888.444.4125 or info@flagshipsgi.com.

Tags: MSA, civil monetary penalties, Robert Finley, Flagship Services, CMP, MSP, Medicare, Medicare Second Payers, section 111

Robert J. Finley

Written by Robert J. Finley

Robert J. Finley, a partner with Hinshaw & Culbertson LLP, has litigation and trial practice experience focused in tort, employment and healthcare. He also counsels firm clients under health plans, auto, property/casualty, no-fault, and workers compensation policies on Medicare repayment and Medicaid reimbursement compliance. Robert advises Flagship Services Group on high value matters, in administrative hearings, and with educational solutions involving Medicare Secondary Payer issues. For more information, visit: https://www.hinshawlaw.com