CMS Extends Development Letter Response Time in Updated WCMSA Reference Guide

Thursday, January 15, 2015

On January 5, 2015, the Centers for Medicare and Medicaid Services (CMS) released an updated WCMSA Reference Guide, Version 2.3, which can be found here. The WCMSA Reference Guide provides the policies and procedures by which CMS and its contractor review Workers' Compensation MSAs submitted for approval. Since first being released in March 2013, CMS has made several updates to the guide.

The most notable update in this version of the Reference Guide is to extend the time to respond to Development Letters from 10 to 20 business days before the submission is considered closed. Development Letters are utilized by CMS to request additional documentation or information CMS finds necessary to complete its review of the proposed WCMSA. A common Development Letter request is for updated medical records and/or prescription history, which typically takes longer than 10 business days to obtain.

In addition to the Development Letter change, the Reference Guide also added language to address the schedule change for hydrocodone compounds from schedule III to schedule II, which had been previously announced in a November 17, 2014 notice on the CMS website. In regard to Hydrocodone Combination products, the Reference Guide states as follows:


Hydrocodone combination products were reclassified effective October 2014 from C-III controlled substances to C-II controlled substances. Normally, C-IIIs require a new prescription after five refills or after six months, whichever occurs first. C-IIs require new prescriptions at intervals no greater than 30 days; however, a practitioner may issue up to three consecutive prescriptions in one visit authorizing the patient to receive a total of up to a 90- day supply of a C-II. WCMSA guidelines changed on January 1, 2015 for all new cases submitted after that date to allocate a minimum of 4 healthcare provider visits per year when schedule II controlled substances (including hydrocodone combination products) are used continuously, unless healthcare provider visits are more frequent per medical documentation

The result of this policy change is to require a minimum of four physician visits be included in the WCMSA when a hydrocodone combination product is being utilized. Examples of hydrocodone combination products are Vicodin, Lortab and Norco.

A full list of the changes in Version 2.3 of the Reference Guide can be found on page 1 of the guide.

A notable omission from the updated Reference Guide was to change to the WCMSA Re-Review process, which had been proposed, but not implemented, by CMS in February 2014. CMS also made no mention in the updated Reference Guide of the prescription drug look-up tool which was added to the Workers' Compensation Medicare Set-Aside Portal (WCMSAP) on October 6, 2014.

Finally, on January 5, 2015, CMS released an updated Self-Administration Toolkit for WCMSAs, Version 1.1, which can be found here. The toolkit is designed to assist claimants with understanding their responsibilities in selfadministering their WCMSAs. Included in the toolkit are sample letters and forms to be utilized in the process of self-administering the WCMSA. Version 1.1 of the Toolkit contains only minor revisions.

ExamWorks Clinical Solutions will continue to keep you apprised of updates to the WCMSA review process as well as all relevant Medicare Secondary Payer compliance developments.

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