On April 1, 2021, CMS held its scheduled Town Hall with the Benefits Coordination & Recovery (BCRC) and Commercial Repayment Center (CRC) for Non-Group Health Plans (NGHP). Although parts of the Town Hall included information that was already disseminated by CMS in the past, there were some specific highlights as noted below.
Partial Resolution of Ongoing Responsibility for Medical (ORM)
CMS addressed how to report on those claims where ORM is terminated for one injury and remains open on another. Specifically, CMS gave the following examples:
Scenario One: Two (or more) injuries claimed/alleged on the same claim under the same insurance type. The RRE assumes ORM for one (or more) alleged injuries, but not for all injuries that were claimed and alleged. The RRE then settles with a Total Payment Obligation (TPOC) settlement, judgment, award, or other payment for injuries claimed or released, but not covered by ORM. Both ORM and TPOC are for the same insurance type, policy and claim number but for different injuries.
The RRE action would include sending two add records. The first, for ORM with ‘0’ in the action type; ICD codes describing all injuries for which ORM was assumed; and ‘Y’ in the ORM Indicator. The second, for TPOC with ‘0’ in the action type; ICD diagnosis codes describing all alleged injuries claimed and/or released related to the TPOC; ‘N’ in ORM indicator; and TPOC amount.
Scenario Two: ORM ends for one injury due to TPOC, continues for another. Claim previously submitted and accepted with ORM ‘Y’ and ORM assumed for multiple diagnosis codes/injuries. ORM then ends for one or more of the injuries, but not for others.
The RRE action would include sending one add and one update record. The update record would include ‘2’ in the action type. ICD codes updated for only those injuries RRE continues to have ORM. The second add record is for TPOC with ‘0’ in the action type; ICD codes describing all injuries claimed or released with TPOC; ‘N’ in ORM indicator; and enter TPOC dates and amounts.
Scenario Three: ORM Ends for one injury and continues for another/others. The claim was previously submitted and accepted for ORM ‘Y’ with multiple injuries listed. The ORM subsequently ends for one or more the injuries but no all injuries.
RRE action would include an update record to CMS with a ‘2’ in the action type and should reflect only those ICD codes for which RRE continues to have ORM. ORM termination would only be submitted when ORM ends for all of the alleged injuries.
While Scenario One and Two are documented in the NGHP User Guide, Chapter IV-Technical Requirements, Scenario Three will be further addressed in a New User Guide set for release in June. Scenario Three also adds additional challenges to both CMS and the RRE. For multiple injury cases, RREs will have to continue to monitor when and how injuries settle if they are not all being addressed at the time of ORM termination and/or TPOC. This is arguably a function that RREs do not have the capability to monitor internally. In addition, CMS will have to track recovery efforts and remove resolved injuries on a continuing basis until ORM is fully terminated. This may present many technical challenges and create continued confusion in the Section 111 and recovery process.
CMS also fielded several questions including reporting diagnosis codes when ORM has been assumed for a No-Fault claim. Pursuant to CMS guidance, payment of medical is not the only action that can create an ORM obligation. This also occurs when the RRE has assumed or is responsible for ORM even without an initial payment being made. Callers noted when assuming ORM in No-Fault situations, oftentimes there is no clear diagnosis or injury recorded and they can be left reporting unclear or incomplete information. CMS warned against the dangers of over-reporting prematurely before injuries are diagnosed and stated they would address this issue further.
CMS also noted that it will not be posting the Town Hall materials on the website as there were no new policies or formal side deck being released for the Town Hall.
NuQuest will continue to monitor MMSEA Section 111 Reporting developments and updates. In the interim, please let us know if you have any questions or would like to discuss our reporting services in further detail. Please contact the NuQuest Settlement Consultant Team at: [email protected].