CMS Concludes 2011 with a New User Guide and Alert
Republished with permission from Gould & Lamb
While many of us were enjoying the holidays, CMS was busy publishing both a new Section 111 Medicare, Medicaid Secondary Payer Mandatory (MMSEA) Reporting Non-Group Health Plan (NGHP) User Guide Version 3.3 and an Alert regarding submission of Third Party Administration (TPA) in the Tax Identification (TIN) reference file.
Amendments to the User Guide include corrections of typographical errors and section updates corresponding to Alerts posted by CMS subsequent August 17, 2011. There were also some important clarifications and additions in the new Version 3.3 to note.
New Annual Profile Report
Specificity has been added to Section 8.2 Registration and Account Setup Process. The section advises that a new annual Profile Report data accuracy process will begin as of January 1, 2012. A time period of 10 days has been specified in which the Authorized Representative (AR) must respond to the EDI Representative regarding accuracy of information on the Responsible Reporting Entity’s (RRE’s) Profile Report. Should the AR fail to respond within 30 days, a ‘non-receipt’ e-mail will be sent to the AR and Account Manager. Failure to confirm information post the non-receipt e-mail may result in RRE deactivation.
Section 11.10.2 What Claims Are Reportable/When Such Are Such Claims Reportable, was amended by two Alerts issued September 30, 2011; Reporting Exception Related to Certain Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers’ Compensation Total Payment Obligation to the Claimant (TPOC) Settlement, Judgments, Awards, or other Payments, Where the Funds At Issue Have Been Paid Into a Qualified Settlement Fund (QSF) Under Section 468B of the Internal Revenue Code (IRC) Prior to October 1, 2011 and Liability Insurance (Including Self-Insurance): Exposure, Ingestion, and Implantation Issues and December 5, 1980 (12/5/1980).
The reporting exception regarding Liability, No-Fault and Workers’ Compensation TPOCS states that, in those claims which do not involve on-going responsibility for medical (ORM) and where there had been a TPOC where funds had been paid into a Qualified Settlement Fund (under Section 468B of the Internal Revenue Code in connection with a State or Federal bankruptcy) prior to October 1, 2011, reporting under MMSEA Section 111 will not be required if all criteria are met.
The reporting exceptions for Liability Insurance regarding exposure, ingestion and implantation and the December 5, 1980 CMS Date of Incident issues are, however, much more complex. In brief, the section provides much needed clarification regarding the determination of the CMS Date of Incident and provides a very helpful table which illustrates examples intended to assist the RRE in policy making decisions.
Lastly, an important note has been added to Section 12.1 Disposition Codes, ‘SP’ Disposition Code – Record in Error. This note indicates that RREs should not submit records known to be missing required data elements and should obtain information to correct known errors prior to submission of claim records. Gould & Lamb provides its customers and their claim administrators with several tools to ensure submission of quality data; weekly Claim Status response files providing claim record data validation, real-time data validation in the GL-Service web portal, monthly Management Reports as well as the GL-Code ICD-9 searchable database of CMS accepted cause of injury and diagnosis codes.
TIN Reference File
On December 28, 2011 CMS published an Alert titled “Information on the Submission of Third Party Administration (TPA) Information for Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers’ Compensation Responsible Reporting Entities (RREs).” The alert provided a temporary solution for RREs to submit TPA information using the existing Section 111 TIN Reference File fields. The Alert contains an important note which advises that, should an RRE submit its TPA’s address on the Section 111 NGHP TIN Reference File, all correspondence related to a recovery case will only be sent by the Medicare Secondary Payer Recovery Contractor (MSPRC) to the TPA. The RRE is still ultimately responsible for Section 111 reporting and MSP compliance.
As 2011 concludes a full year of mandated Section 111 reporting for No-Fault and Workers’ compensation and the beginning of a New Year and mandated reporting for Liability claims, CMS has evidenced a tightening of requirements and specifications as evidenced by the amended User Guide language and Alerts.
These evolutionary changes underscore the need for a Reporting Agent who is not only a subject matter expert but a partner with the knowledge and experience to guide RRE’s and TPA’s on the road to compliance. Does your Reporting Agent fit the bill? If not, contact Gould & Lamb at 866-MSA-FILE.
About the Author:John Miano is the Manager of Reporting Services for Gould & Lamb, LLC. His primary responsibility is directing the implementation of CMS Section 111 reporting programs for our clients. He has over 20 years experience in the Property and Casualty Insurance Industry and is currently an active committee member of the International Association of Industrial Accident Board Committees (IAIABC). He is also a former Executive Board Member of the Association of Workers Compensation Claim Professionals (WCCP) and is a Board Certified Workers Compensation claim adjuster (CWC).
Gould & Lamb is a global leader of MSA/MSP Compliance Services in the country, serving domestic and international insurance companies, third-party administrators and self-insured entities.
Be the first person to comment!
You must Login or Register in order to read and make comments!
Disclaimer: WorkersCompensation.com publishes independently generated writings from a variety of workers' compensation industry stakeholders. The opinions expressed are solely those of the author and do not necessarily reflect those of WorkersCompensation.com.