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New WCMSA Reference Guide, 3.2, clarifies specific medical center used for WCMSA pricing

October 9, 2020 · Optum Workers' Comp and Auto No-fault

The Centers for Medicare and Medicaid Services (CMS) released Version 3.2 of the Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide, which clears up how pricing is determined for services rendered at a major medical center.


The new Reference Guide, posted October 5, 2020, provides a list of major medical centers used by the Workers’ Compensation Review Contractor (WCRC). This list of centers is used to establish pricing associated with medical services such as a surgery, hospital stay, long-term in-patient care, etc. The list of the zip codes is found in Appendix 7 of the Guide and should follow the same process as outlined for selecting the proper jurisdiction for determining pricing. 

CMS also added a new screen to the WCMSA Portal (WCMSAP) on October 5, which requires the submitter to answer the question, “Does the proposed WCMSA for this settlement include any costs associated with a major medical center, Yes or No?”  If the answer is yes, then the appropriate zip code for the major medical center that was used in the calculation of the WCMSA needs to be entered into the space provided.

This enhancement should improve the WCMSA process. In the past, it has not been clear which major medical center the WCRC used to price WCMSAs. The new process should reduce the number of counter higher determinations received on WCMSAs. The industry has been asking CMS/WCRC to clarify this issue for some time and Optum is pleased to see that this has been addressed in the WCMSA Reference Guide. 

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