CMS has an updated guideline regarding request for review after an MSA has been submitted.
When the following criteria are met, CMS will permit a one-time request for re-review :
- CMS has issued a conditional approval/approved amount.
- The case has not yet settled as of the date of the request for re-review.
- Projected care has changed so much that the submitter’s new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount.
- Request must include submission of a new cover letter, all medical documentation related to the settling injury(s)/body part(s) since the previous submission date, the most recent six months of pharmacy records, a consent to release information, and a summary of expected future care
- When a re-review request is reviewed and approved by CMS, the new approved amount will take effect on the date of settlement, regardless of whether the amount increased or decreased.
Additional criteria may apply depending on case circumstances.
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