What Can a Practitioner Expect from the CMS Review Process?

The first step in getting a Medicare set aside (MSA) approved by the Centers for Medicare and Medicaid Services (CMS) is to consult with a qualified MSA professional, such as a nurse case manager or attorney, to determine if an MSA is appropriate for your particular case. The MSA professional or vendor will then gather all necessary documentation, including medical records, pharmacy printout, payment history and signed Consent Form. Once received, the MSA professional will then prepare a proposal outlining the estimated future medical and prescription expenses for the proposed MSA allocation.

The proposal is then submitted to CMS for review and approval. CMS will review the proposal and may request additional information or clarification before making a decision on whether to approve the MSA. Once they have all of the documentation they need, CMS will typically provide a response outlining whether they agree with the amount proposed or require a different amount to consider their interests within about three to four weeks.

If the MSA is approved, CMS will issue a letter outlining the approved amount for the MSA and the conditions that must be met for the MSA to be considered complete. Once the case settles, CMS requires that the final settlement documents be provided to them to finalize the process. The MSA funds must then be set aside and managed in accordance with CMS guidelines. These guidelines include placing the funds in a separate interest bearing account and using the funds only for injury related medical expenses that are covered by Medicare. Once the MSA funds have been properly exhausted, further injury related bills can be submitted to Medicare for Payment.