The Centers for Medicare and Medicaid Services (CMS) has updated its Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide to document the current WCMSA review process and provide more detailed information on the actions performed by the Workers’ Compensation Recovery Contractor (WCRC). The updated Reference guide can be found here. The following sections of the Guide have been enhanced or added:
9.4.1.1 Most Frequent Reasons for Development Requests: The five most common omissions as provided by the WCRC.
9.4.2 WCRC Team Background and Resources Used: The expertise of the WCRC reviewers as well as the resources used when reviewing a WCMSA.
9.4.3 WCRC Review Considerations: Examples of the questions and factors that guide the WCRC’s review of WCMSA proposals. The overarching guidelines used in treatment allocations and pricing is also provided.
9.4.4 Medical Review: A diagram and steps the WCRC follows in its medical review process with a general explanation of documentation requirements.
9.4.5 Medical Review Guidelines: Considerations and examples in specific medical cases and topics.
9.4.6.1 Prescription Drug Review: Details the process the WCRC follows in reviewing prescription medication allocations and the resources that may be used.
9.4.6.2 Pharmacy Guidelines and Conditions: Discusses specific drug usage and pricing considerations.
10.1.8 Pay history added to list of information needed for WCMSA submission.