Non-Group Health Plan (NGHP) Conditional Payment Letter

Trigger: The MSPRC creates a CPL upon reciept of a valid authorization.

The MSPRC provides beneficiaries and their representatives with a (Interim) Conditional Payment Letter (CPL) as an estimate of the refund due to Medicare. Liability attorney's use this information to estimate Medicare's interest in a case before they settle.

Once a lead is established by the Coordinator Of Benefits Contractor (COBC) in the Common Working File (CWF), automated computer systems start collecting Medicare payments beginning from the Date Of Incident (DOI).

Since the computer system returns all of the claims from the DOI, Case Analysts must weed out claims that are not "related" to the incident. For instance, a beneficiary that injured a leg in an automobile accident may have had a flu shot or been treated for asthma since the incident and these claims will be part of the collection. Case Analysts evaluate the claims for "relatedness" and delete those that were not related to the incident. Although these employees are conscientious, well trained and supported by in-house industry experts, they are not generally Certified Coding Specialists (CSS). In order to improve the accuracy of the estimate, the MSPRC implemented Ingenix Enterprise Treatment Groups® ETG® technology. This technology has improved the consistency of the estimates, but the estimates still vary according to the skill and experience of the case analyst. Beneficiaries and their representatives should carefully review the estimate.

if a beneficiary, or their representative, believes the CPL is in error, they can dispute the CPL.


Disclaimer -- Piatt Consutling and our staff cannot render legal, accounting or medical service.  We can only try to provide accurate and authoritative information in regard to the subject matter covered.  If legal advice or other expert assistance is required, the services of a competent professional in that area should be sought.