Referral Form

CCP REFERRAL FORM
Referring Party Information
Your Name*

First NameLast Name
Your Company*
Your Email *
Your Phone *
I am the....*

AdjusterBroker/Settlement PlannerDefense AttorneyPlaintiff AttorneyOther
Claim Type
Claim Type*
Workers' Compensation Service(s) Requested
Please Provide: (check all that apply) *

Work Comp (WC) Medicare Set-Aside (MSA)Work Comp (WC) Medical Cost Projection (MCP)Revision of an existing WC Medicare Set-AsideRevision of Existing WC Medical Cost ProjectionSubmission of WCMSA to CMSWC Conditional Payment ResolutionEntitlement VerificationDrug Utilization ReviewProfessional Administration
Liability Service(s) Requested
Please Provide: (check all that apply) *

Liability Medicare Set-AsideLiability Medical Cost ProjectionRevision of an existing LiabilityMedicare Set-AsideRevision of an existing Liability Medical Cost ProjectionLiability Conditional Payment ResolutionEntitlement VerificationProfessional Administration
MSA or MCP Turnaround Time
I need report in

10 Business Days5 Business Days (Rush Fee Applies)3 Business Days (Rush Fee Applies)Other
Injured Party Information
Injured Party *

First NameLast Name
Injured Party Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Injured Party Date of Birth*

MonthDayYear
SSN*
Current Date

MonthDayYear
Entitlement Information
Medicare Entitlement*
SSDI Entitlement*
Claim Information
Jurisdiction*
Date of Injury *

MonthDayYear
Claim #
Additional Dates of Loss
Date of Injury (2)

MonthDayYear
WC Claim # (2)
Date of Injury (3)

MonthDayYear
WC Claim # (3)
Date of Injury (4)

MonthDayYear
WC Claim #(4)
Related Conditions / Body Parts*
Denied or Excluded Conditions /Body Parts*
Insurance Company, Self Insured or TPA*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Adjuster Name: *

First NameLast Name
Adjuster Phone Number*

Area CodePhone Number
Adjuster Email*
example@example.com
Employer Name*
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal Counsel
Defense Attorney

First NameLast Name
E-mail
example@example.com
Defense Firm
Phone Number

Area CodePhone Number
Defense Firm Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Plaintiff Attorney

First NameLast Name
E-mail
example@example.com
Plaintiff Firm
Plaintiff Firm Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Special Instructions
~ Anything important that we need to know ~
Information Requirements

What we need to get the job done!
Workers' Compensation Medicare Set-Aside
For Workers' Compensation MSA or MCP:

- Medical records detailing the most recent 24 months of treatment.

- A claims payment history detailing all payments made from the claim file in the most recent 24 months. The date printed should be visible on the document.

- A pharmacy (PBM) summary detailing prescriptions filled relative to the work injury the most recent 24 months. The summary should include the name, strength, prescriber and # of units dispensed.

- Include First Report of Injury if available

The Turnaround time is dependent on your needs. See the Requested Turnaround Section near the top of the page.
Liability Medicare Set-Aside
For a Liability MSA or MCP:

- Medical records detailing the most recent 24 months of treatment.

- A print out from the injured party's pharmacy detailing prescriptions filled during the most recent 12 months. The summary should include the medication name, strength, dose, # of units dispensed, and date dispensed.

- Include a copy of the complaint.

The Turnaround time is dependent on your needs. See the Requested Turnaround Section near the top of the page.
WCMSA Submissions to CMS

This is what we need to process a CMS Submission:
- The MSA must have been written or revised within six months of submission.

- Proposed or actual settlement amount

- Consent signed by the Injured Worker (See last page of MSA)

- Administration of the MSA Funds: Will the MSA funds be professionally administered or administered by the Injured Worker?

Turn Around Time: We strive to forward all WCMSA submissions to CMS for review within 24-48 business hours of receiving all necessary documentation required by CMS.

As of 2018, review and approval time for submissions is approximately 33 business days. On some occasions, when CMS feels they do not have enough information to render a decision, a "development" letter will be sent requesting additional records or documentation. Submissions that are flagged for development will experience increased processing time, typically an additional 30 days from the date CMS receives the requested information.
Entitlement Verification
Entitlement Verification

An SSA-3288 Form signed by the injured party.

The form is available for download by clicking the link below:

https://www.ssa.gov/forms/ssa-3288.pdf

Entitlement Verification may take anywhere from 60-90 days once the signed form is received by us. The verification process requires that we communicate directly with the Social Security Office nearest the injured party's residence. The Social Security office will provide a written response regarding the individual's entitlement to SSDI and/or Medicare.
Drug Utilization Review (DUR)
Drug Utlization Review

We will use the current Medicare Set-Aside (if one is available) along with the documents supplied to us at the time of the MSA referral. If additional information is needed, you will receive a call or email from the referral coordinator.

Turn Around time: Our DURs are performed by an independent Pharm. D. and are ready for delivery to the client within 14 business days.
Conditional Payments: Workers' Compensation
In addition to the completed referral information gathered above we need the following:

- Description of Injury

- Any and all correspondence previously received from CMS/CRC

- A Letter of Authority signed by the referring party (unless currently on file).

Turnaround time: Conditional Payment Resolution takes time, so please be patient. We will begin communicating with Medicare on your behalf promptly, however, the departments within Medicare which resolve conditional payments (CRC/BCRC) frequently experience significant back log and delays. Rest assured we are working diligently on your behalf to identify, dispute, appeal, and resolve all conditional payment files with Medicare as swiftly and acurately as possible.
Conditional Payments: Liability
In addition to the completed referral form we will need the following:

- Description of Injury

- Any and all correspondence previously received from CMS/BCRC

- In liability Conditional Payment resolution cases we need a Proof of Rep (POR) form signed by the injured party. You can download a POR form here:

https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Beneficiary-Services/Medicares-Recovery-Process/Downloads/Proof-of-Representation-Model-Language.pdf

Turnaround time: Conditional Payment Resolution takes time, so please be patient. We will begin communicating with Medicare on your behalf promptly, however, the departments within Medicare which resolve conditional payments (CRC/BCRC) frequently experience significant back log and delays. Rest assured we are working diligently on your behalf to identify, dispute, appeal, and resolve all conditional payment files with Medicare as swiftly and acurately as possible.
Professional Administration
Professional Administration

You will be contacted by one of our team of professionals to discuss the necessary documentation required to create a Professional Administration Account.
Document Upload

After clicking the "Submit" button, you will receive a link to a secure file sharing folder. Please upload the necessary documentation based on the product requested. Our staff will receive notification of the file upload and begin preparing the case for completion timely.
Date
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CCP REFERRAL FORM

Referring Party Information

Claim Type

Workers' Compensation Service(s) Requested

Liability Service(s) Requested

MSA or MCP Turnaround Time

Injured Party Information

Entitlement Information

Claim Information

Legal Counsel

Special Instructions

Information Requirements

Workers' Compensation Medicare Set-Aside

Liability Medicare Set-Aside

WCMSA Submissions to CMS

Entitlement Verification

Drug Utilization Review (DUR)

Conditional Payments: Workers' Compensation

Conditional Payments: Liability

Professional Administration

Document Upload