I have a workers’ compensation claim which occurred on May 20, 2003. We reached a compromised settlement of $60,000 plus $7,500 for medical. Since I represent myself, the workers’ compensation commissioner thought this was insufficient to cover medical expenses and we are currently waiting on a Medicare Set-Aside allocation. It has now been 6 months and, with the exception of a letter from the workers’ compensation commissioner indicating the file was being returned to the general file until clincher documents are complete, I haven’t
heard anything. Should I file an appeal or just wait on Medicare? The defense attorney has told me that it takes a long time to resolve the Medicare set aside.
Thanks for your help.
I cannot advise you on the specifics of your claim. However, it sounds like you have a North Carolina workers’ compensation claim that is being held up by the successful prosecution of a Medicare Set-Aside arrangement (MSA). Getting CMS approval should not be a long process. Based on our experience, it should take no longer than 90 days. If you have been waiting six months then something has gone wrong. Either the submission was incomplete or CMS has requested additional information that has not been provided.
I would ask defense counsel to follow up with its MSA providor and obtain the CMS case control number. With that information, it would be possible to follow up with CMS and ascertain the status of your claim. I would not continue to just wait. If you have not received approval by now, then some type of specific action is needed on your claim or CMS will likely close its file altogether.
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