Updated User Guide – Section 111 Non Group Health Plans, version 5.3:

A carrier or self-insured may have a responsibility to report to Medicare an Ongoing Responsibility of Medical (ORM) or a Total Payment Obligation to Claimant (TPOC) where there is a workers’ compensation or liability claim that involves a Medicare beneficiary. TPOCs usually are payments to a claimant after a settlement, judgment or award. These reporting requirements are commonly referred to as “Section 111” reporting.

The Centers for Medicare and Medicaid Services (CMS) provide a Section 111 Medicare Secondary Payer Mandatory Reporting User Guide for Liability, No-Fault and Workers’ Compensation claims (user guide).  This user guide discusses how Medicare expects ORM or a TPOC to be reported to Medicare through Section 111 reporting.  CMS recently published an updated version of the user guide, numbered 5.3, and a link to the updated version can be found at CMS’ website or by clicking here.

For background, the user guide has five chapters: I – Intro and Overview, II – Registration, III – Policy, IV – Technical Information and  V – Appendices. The 5.3 version provided updates to the following areas of the user guide:

  • Overall: Medicare will begin to use the Medicare Beneficiary Identifier (MBI) in its correspondences and query responses to parties instead of a beneficiary’s Social Security Number (SSN) or Health Insurance Claim Number (HICN). MBIs are being issued to Medicare beneficiaries as a part of the discontinuation of social security number based HICNs.
  • Data exchange escalation contact protocol (Chapter I, Section 8.2 and Chapter IV, Section 13.2)
  • Termination of Ongoing Responsibility for Medical (ORM) (Chapter III, Section 6.3.2)
  • ICD-10 exclusions (Chapter V, Appendix I and J)

Regarding MBIs, CMS has excluded the Medicare Secondary Payer processes from requiring stakeholders to exclusive use of a MBI.  This means, a claimant’s SSN, HICN or MBI will be accepted by Medicare for entitlement queries and matching data for submission of documentation and disputes. However, the parties should be aware that Medicare’s response may use the MBI, if available.  More about the Social Security Number Initiative and MBIs can be found here.

The data exchange protocol has now been amended to exclude contacting a particular employee within BCRC.  If there is a data exchange issue, the Responsible Reporting Entity (RRE) is to first contact their Electronic Data Interchange (EDI) representative (or contact BCRC to obtain one). If there is no response from the EDI representative within two business days, the RRE should contact the EDI Director, Jeremy Farquhar.  If Mr. Farquhar does not response in one business day, the RRE should contact the BCRC Project Director, Jim Brady. The contact information for these two individuals is located in the user guide.

Section 6.3.2, ORM Termination, was added to the user guide to include additional explanation of when termination of ORM may occur. CMS advises that when ORM ends, the RRE should report the date ORM terminated and not delete the record.  Additionally, termination of ORM does not require the reporting of a Total Payment Obligation to Claimant (usually settlements).

In sum, CMS states that ORM termination should be submitted where ORM is not subject to reopening or additional request for payment of medicals and one of the following criteria is met:

  • Termination of ORM can be reported where there is “no practical likelihood of associated future medical treatment and the RRE maintains a statement (hard copy or electronic) signed by the beneficiary’s treating physician that no additional medical items and/or services associated with the claimed injuries will be required;
  • Where insurer’s responsibility for ORM is terminated under applicable state law associated with the insurance contract; or
  • Where the insurer’s responsibility for ORM has been terminated per the terms of the pertinent insurance contract, such as maximum coverage benefits.”

Although the concept of ORM is not new to the industry, this new section of the user guide highlights the importance of an RRE’s protocol to determine: (1) whether ORM needs to be reported; (2) If ORM does need to be reported, what conditions should be reported; and (3) whether termination of ORM should be submitted.

Lastly, CMS has issued a list of ICD10 and corresponding ICD9 codes that will not be accepted by BCRC for section 111 reporting.  A full list of the excluded codes may be found at Chapter V, Appendix I and J of the MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting User Guide, version 5.3, 12/15/2017.

We will keep you posted on more updates to the Section 111 user guide, as they are available.

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