|
CMS Memo Updates TPOC Reporting |
PDF |
| Print | |
|
Industry News Updates
|
|
Written by Tom Matson
|
|
Tuesday, 14 April 2009 00:00 |
|
On April 7, 2009 CMS issued an alert changing how non-GHP RREs will report multiple TPOC dates and amounts on the claim input file for Section 111 reporting. CMS has attempted to clear up the confusing nature of reporting multiple Total Payment Obligations to the Claimant, or TPOC. The previous information left doubt as to how an RRE would report updates to multiple TPOC amounts that had already been reported. The new memo provides the following example: Suppose a TPOC Amount and Date were reported on an add record for a Workers’ Compensation indemnity settlement and subsequently an update record was submitted with an Action Type of ‘3’ to report a different, additional TPOC Amount and Date, for the same claim, reflecting a settlement for lost wages. The current file layout and processing requirements do not provide the flexibility for an RRE to subsequently update one of these specific TPOC Amounts and/or Dates if necessary. Previously it was thought that in order to update an already reported record, the RRE would have to enter a 3 in the “Action Type” field. However, at that point the RRE was not given any option to update those files if necessary. The new process has eliminated the option to enter a 3. Instead four additional TPOC amount fields as well as the corresponding TPOC date fields have been added to the end of the Claim Input File Auxillary Record layout. In addition, a “Funding Delayed Beyond Start Date” field has also been added. These new fields only need to be submitted if the RRE has more than one additional TPOC to report for a claim. For additional details on this update, please click here. |
|
|
CMS Opportunity to Comment |
PDF |
| Print | |
|
Industry News Updates
|
|
Written by Tom Matson
|
|
Saturday, 11 April 2009 00:00 |
|
On April 10, 2009, CMS released another memo regarding Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007. There has been a plethora of information released on this topic by CMS and other resources, and CMS is providing a forum for public comment as we get closer to the implementation time period. This forum will be held via email, and CMS has established the following address for comments:
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
It is important to note that submitters should be as specific as possible in their subject line, and only one topic is requested per email. If one needs to address more than one topic than they should divide their issues into multiple emails. Comments will generate an auto-reply, and all emails gathered will give CMS the information they need to address in future memos and publications. To view this latest CMS memo in its entirety, please click here. |
|
CMS to Review Pharmacy Portion of MSA |
PDF |
| Print | |
|
Industry News Updates
|
|
Written by Tom Matson
|
|
Monday, 06 April 2009 00:00 |
On April 6, 2009, The Center for Medicare and Medicaid Services (CMS) announced its preferred method of pricing the future prescription costs in a Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) proposal. Effective June 1, 2009, CMS will begin independently pricing the future prescription costs of these proposals using Average Wholesale Price (AWP). The memo goes onto state that they “will not use or recognize any other pricing, discounting, or calculation methods when determining the adequacy of the prescription drug amounts in WCMSA proposals.”
This memo also states that if future prescription costs are not included in the WCMSA proposal, but the Coordination of Benefits (COB) contractor deems that future prescriptions are necessary, CMS will utilize AWP for brand name drugs when determining the sufficiency of the prescription drug amount. Also, if a proposal if priced according to “generic” pricing and the COB determines that a “generic” drug is not available, the proposal will be re-priced using brand name pricing.
While this latest memo does not specifically come out and say it, one is now lead to the conclusion that CMS will now be reviewing the future prescription costs on WCMSA proposals. This move appears to have put to rest the sometimes heated debate regarding the “donut hole” within WCMSAs. Previously there were some who felt that the Medicare Part D deductibles, the donut hole, should be taken out of WCMSAs. There were others who felt it was a direct violation of the Medicare Secondary Payer statute to do so, and subsequently did not account for the donut hole within their specific proposals. What we can all agree on is that CMS left the window open for debate since they were not reviewing the future prescription costs of a WCMSA proposal anyway. Whatever position one may have taken on that issue, it is now clear that CMS has closed the window and will now be reviewing the WCMSA proposals in their entirety.
To view this latest memo in its entirety, please click here. |
|
CMS Common Working File (CWF) Update |
PDF |
| Print | |
|
Industry News Updates
|
|
Written by Tom Matson
|
|
Wednesday, 25 March 2009 00:00 |
On March 20, 2009 the Centers for Medicare and Medicaid Services (CMS) notified their Medicare contractors of a new MSP code in Medicare’s Common Working File (CWF). The goal of this new code is to give the CMS the ability to better identify claims in which they should be the secondary payer due to a Workers’ Compensation Medicare set-aside arrangement (WCMSA).
The CMS’ previous process of applying a “WCSA” in the MSA Auxiliary File never insured that a conditional payment would not be made for a particular claim that should have been paid from a WCMSA. CMS believes that the introduction of this new MSA code will enable them to issue automated denials of claims and diagnosis codes that are associated with an open WCMSA. The contractors will notify the Medicare beneficiary of the denial by using the Medicare Summary Notice 29.33 which states: “Your claim has been denied by Medicare because you may have funds set aside form your settlement to pay for your future medical expenses and prescription drug treatment related to your injury(ies).”
To view this official instruction in its entirety, please click here. |
|
CMS Extends Testing Period, Clarifies Interim Reporting Thresholds |
PDF |
| Print | |
|
Industry News Updates
|
|
Written by Tom Matson
|
|
Friday, 20 March 2009 00:00 |
Today the Center for Medicare and Medicaid Services (CMS) announced that they have extended the permissible testing period for Section 111 files through December 31, 2009. Previously the testing period began on July 1, 2009 and ran through September 31, 2009. CMS was, however, quick to clarify the RREs must still register and start testing as scheduled. RREs are also still required to begin live production submission no later than their assigned submission window in the January – March quarter of 2010, however, if testing is completed prior to January 2010, they may begin submitting live production files in the October – December quarter of 2009.
Within this alert, CMS has also attempted to clarify the Interim Reporting Thresholds surrounding “Ongoing Responsibilities for Medicals” (ORM), and “Total Payment Obligation to the Claimant” (TPOC).
For no-fault and liability insurance, including self-insurance, there is no minimum dollar threshold for reporting the assumption/establishment of ORM or for reporting TPOC. For workers’ compensation ORM claims, all of the following criteria must be met to be excluded from reporting through December 31, 2010:
- a. “Medicals only”
- b. “Lost time” of no more than 7 calendar days
- c. All payment(s) has/have been made directly to the medical provider
- d. Total payment does not exceed $600.00.
For liability insurance (including self-insurance) and workers’ compensation TPOCs, the following dollar thresholds apply:
- a. For TPOCs dates of July 1, 2009 through December 31, 2010, TPOC amounts of $0.00 - $5,000.00 are exempt from reporting except as specified in “d’ below.
- b. For TPOCs dates of January 1, 2011, through December 31, 2011, TPOC amounts of $0.00 - $2,000.00 are exempt from reporting except as specified in “d” below.
- c. For TPOCs dates of January 1, 2012 through December 31, 2012, TPOC amounts of $0.00 - $600.00 are exempt from reporting except as specified in “d” below.
- d. Where there are multiple TPOCs reported by the same RRE on the same record, the combined TPOC amounts must be considered in determining whether or not the reporting exception threshold is met. For TPOCs involving a deductible, where the RRE is responsible for reporting both any deductible and any amount above the deductible, the threshold applies to the total of these two figures.
As is usually the case, CMS has made sure to note that these thresholds are “solely for purposes of the required reporting responsibilities for purposes of Section 111 MSP reporting requirements. These thresholds are not exceptions/do not act as a “safe harbor” with respect to any other obligation or responsibility of any individual or entity with respect to the Medicare Secondary Payer provisions.” They are also meant to be interim thresholds while CMS implements the reporting process and they have reserved the right to change these thresholds at anytime.
To view this alert in its entirety, please click here. |
|
|
|
|
<< Start < Prev 1 2 3 4 5 6 7 Next > End >>
|
|
Page 6 of 7 |
Blog
