The denial reads:
PR 201 Workers’ Compensation case settled. Patient is responsible for amount of this claim/service through WC Medicare set aside arrangements or other agreement.
According to the report, CMS is required to review workers’ compensation cases if the worker is either a current Medicare beneficiary and the total settlement is more than $25,000, or the worker is not currently a Medicare beneficiary but there is a reasonable expectation of Medicare enrollment within 30 months, and settlement is for $250,000 or more.
Medicare may require a Workers’ Compensation Medical Set-Aside Arrangement, whereby Medicare agrees to address future medical benefits. The patient may be required to pay from a fund controlled by the patient or by another entity, and patients are responsible to cover medical expenses until the funds are used up.
Related Articles on Coding, Billing and Collections:
Surgery Center Coding Guidance: Hand Procedures
4 Things You Should Know About the ASC Quality and Access Act of 2011
Internist Accuses Florida’s Lee Physician Group of Knowingly Overcharging Medicare
https://www.beckersasc.com/asc-coding-billing-and-collections/surgery-center-coding-guidance-hand-procedures.html
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