CMS Extends Testing Period, Clarifies Interim Reporting Thresholds

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.


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