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MEDICARE SET-ASIDE RECORD REVIEW

The allocation is only as defensible as the record behind it.

Medicare set-aside record review reads the full claim file, 300 to 3,000 pages, and returns every injury-related treatment, drug, dosage and frequency, cited to the source page, before the allocation is written. CMS-approved WCMSA and LMSA amounts ran 24% above proposal in FY2025, the highest variance in five years, and the record behind the number is where that gap closes.

Click any row → the source page it cites
Claim file review · Case #IME-4812 review-ready
Adams, Timothy · workers' comp claim file
342 pp / 2 packets received logged
11 duplicate pages removed free
p.140 — wrong patient quarantined
Pages 342 Documents 27 Cited 100%

The rulebook is published. So is the referee.

We do not build for a case type until we can name the standard that defines a correct output and the person who grades the file against it. In Medicare set-aside allocation, both are already federal policy.

The rulebook and the referee
The rulebook
  • CMS WCMSA Reference Guide v4.x — versioned, public, and extraordinarily detailed methodology CMS reviews the allocation against
  • 42 USC §1395y(b) and 42 CFR §411 — the Medicare Secondary Payer statute and its implementing regulations
  • CDC Life Table, Table 1 — the life-expectancy table rated allocations are built against
  • Section 111 reporting — the mandatory reporting obligation tied to the settlement
The referee
  • CMS's Workers' Comp Review Contractor (Capitol Bridge), who issues a written approval or a COUNTER-HIGHER with a dollar figure attached
  • FY2025: 13,884 determinations processed, approved amounts running +$16,540 / +24% above proposal on average, the highest variance in five years
  • The submitter, who owns the allocation once CMS's number lands, higher or not
Allocation reports run $1,200–2,500 (WCMSA) and $1,800–3,500 (LMSA), of which 50–65% is record-review labor Flat 10¢/page here, duplicates free
Claim file extract · Case #IME-4812 cited 100%
Claim file342 pp / 2 packets · 11 deduplicatedlogged
Injury treatment threadImproving since 4/02 · 7 visitstracked
MedicationsExtracted, with dosages & frequenciescited
Non-injury treatmentPresent in file, excluded from extractflagged
Allocation amountNot produced — yours to writeyou
7 visits · cited 100% · no allocation number, no CMS approval
How it works

Three steps between the claim file and the allocation.

01

Send the claim file

The full claim file as you already have it, in any format. In the demo case, 342 pages across 2 packets, with 11 duplicate pages removed before the read starts.

02

We return every injury-related fact, cited

Treatment, drug, dosage and frequency for every visit tied to the accepted injury, each line linked to its source page. Non-injury treatment stays out of the extract, flagged as excluded rather than silently dropped.

03

You write the allocation

The allocator builds the WCMSA or LMSA proposal against CMS's Reference Guide methodology, using the extract as the treatment record. The AI never sets the dollar amount and never predicts CMS's approval.

The boundary, in writing

A record review that knows it isn't the allocation.

We extract the injury-related treatment, drug, dosage and frequency, and cite every page. We do not set the allocation amount, do not predict what CMS's review contractor will approve, and do not give a legal or medical opinion. The WCMSA or LMSA proposal, and the number in it, belong to the allocator.

In the demo case, page 140 turned out to belong to a different patient. The claim-file review flags it and quarantines it in its own line, instead of folding it silently into the record CMS will review.

Audit trail · Case #IME-4812 exportable
08:12Claim file received · 342 pp / 2 packetssystem
08:3111 pages deduplicatedsystem
08:44p.140 flagged — wrong patientsystem
08:54Injury-related treatment extracted · cited 100%system
09:20Extract reviewed · citations verifiedreviewer
09:26Extract exported · WCMSA proposal drafted off-platformreviewer
Every access logged · file deleted 30 days after delivery
Why Medrecords AI

The rules the platform never breaks.

Medrecords AI EVERY LINE CITED
CASE #IME-4812 · ADAMS, T.342 pp
2/14 — ER visit, right knee p.4
4/18 — arthroscopic surgery p.61
p.140 — wrong patient quarantined
Medrecords AI
Read every page · cite every line

HIPAA, under a signed BAA

Every file is handled under our Business Associate Agreement, from the first byte.

Never trains a model

Your records are never used to train any AI model — ours or anyone else's.

Every line cited

If we can't cite it, we don't say it. Every sentence links to its source page.

Deleted after delivery

Files are deleted 30 days after delivery, with a full audit log of every access.

Powered by the platform

Four capabilities behind every claim-file review.

The MSA claim-file review is one deliverable of the same platform that reads, sorts, and cites the whole record.

FAQ

Medicare set-aside record review, answered.

No. We extract and cite the injury-related treatment, drug, dosage and frequency the allocation is built from. The dollar figure is written by the allocator, using CMS's WCMSA Reference Guide methodology.

CMS's Workers' Comp Review Contractor can approve, counter-higher, or ask for more documentation. Our claim-file extract stays available so the allocator can trace any treatment CMS flags back to its source page without re-reading the file.

Yes. Non-submit allocations still need the same injury-related treatment record, cited and organized; whether the proposal goes to CMS for review is a decision the allocator and carrier make separately.

We extract every drug, dosage and frequency found in the record, cited to its source page. Projecting future drug cost against CMS's pricing methodology is the allocator's calculation, not something we produce.

No. MedRecords AI does not retrieve records from providers or facilities. You bring the records you already have — review starts in minutes from upload. Retrieval vendors take days; you can keep yours and still cut the review to minutes.

Send one file. We'll tell you what we can read.

No obligation. If the case type is buildable we'll scope it; if it isn't, we'll say so.