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    CMS Issues Updated WCMSA Reference Guide

    On June 3, 2014, the Centers for Medicare and Medicaid Services (CMS) issued an updated Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide. The following sections of the Guide have been enhanced or added:

    4.1.4          Hearing on the Merits of the Case: Section added to reflect the April 22, 2003 WCMSA RO Memorandum (Question # 5).

    9.4.4          Medical Review – Step 8: Clarification of submission requirements for medical records and payment records.

    10.8          Section 40 – Payment History: Updated requirements for denied conditions.     Pharmacy Guidelines and Conditions:

    • Removed reference to Drug Tables for physician dispensed drugs.
    • Consolidation of Drug Tapering and Drug Weaning sections.

    10.5.2      Use of WC Fee Schedule vs. Actual Charges for WCMSA: Wisconsin added to list of states with no Workers’ Compensation fee schedule.

    10.7          Section 35 – Medical Records:

    • Removed two year requirement of medical records for unrelated to work injury.
    • Clarified treating physician statements requirements.

    10.8          Section 40 – Payment History- Requirements for denied conditions.

    The updated Reference Guide can be found here.

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