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Tag Archive for: Section 111 Reporting

New Section 111 Reporting User Guide Published by CMS (But No New Information Provided on Penalties for Noncompliance)
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New Section 111 Reporting User Guide Published by CMS (But No New Information Provided on Penalties for Noncompliance)

On October 1, 2018 the Centers for Medicare & Medicaid Services (CMS) published a new user guide for entities in the Non Group Health Plan (NGHP[1]) category, regarding Section 111 Mandatory Insurance Reporting under the Medicare Secondary Payer Act’s (MSP)[2] amendment called the Medicare, Medicaid, and SCHIP[3] Extension Act of 2007 (MMSEA). The MMSEA reporting obligations are commonly referred to as Section 111 Reporting or simply Section 111 because they were listed in Section 111 of the Public Law amendment to the MSP[4]. Section 111 requires NGHP entities or in some cases, Third Party Administrators for NGHP entities, as Responsible Reporting Entities (RREs), to report data to CMS about injury claims. The reporting which must be electronically transmitted, is sent to CMS through its Benefits Coordination & Recovery Center (BCRC) contractor, and includes a large amount of information identifying Medicare beneficiaries, their injuries, their legal representatives, dates of injury, dates of payment, whether injury-related payments are ongoing or are paid in lump sums etc., provided the annually updated dollar threshold for reporting (currently $750 for accident or exposure cases) is met.

The updated MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers’ Compensation USER GUIDE (Section 111 User Guide) is now in version 5.4.

Only two changes were announced in the new version of the Section 111 User Guide. The first change was the addition of an updated Paperwork Reduction Act disclosure and the second change was an update to the contact protocol for the Section 111 data exchange escalation process. The updated contact protocol is listed in its entirety below:

8.2 Contact Protocol for the Section 111 Data Exchange
In all complex electronic data management programs there is the potential for an occasional breakdown in information exchange.
If you have a program or technical problem involving your Section 111 data exchange, the first person to contact is your own EDI Representative at the BCRC. Your EDI Representative should always be sought out first to help you find solutions for any questions, issues or problems you have. If you have not yet been assigned an EDI Representative, please call the EDI Department number at 646-458-6740 for assistance.

Escalation Process

The CMS and the BCRC places great importance in providing exceptional service to its customers. To that end, we have developed the following escalation process to ensure our customers’ needs are met. It is imperative that RREs and their reporting agents follow this process so that BCRC Management can address and prioritize issues appropriately.

1. Contact your EDI Representative at the BCRC. If you have not yet been assigned an EDI Representative, please call the EDI Department number at 646-458-6740 for assistance.

2. If your Section 111 EDI Representative does not respond to your inquiry or issue within two business days, you may contact the EDI Director, Angel Pagan, at 646-458-2121. Mr. Pagan’s email is apagan@ehmedicare.com.

3. If the EDI Director does not respond to your inquiry or issue within one business day, you may contact the BCRC Project Director, Jim Brady, who has overall responsibility for the EDI Department and technical aspects of the Section 111 reporting process. Mr. Brady can be reached at 646-458-6682. His email address is JBrady@ehmedicare.com. Please contact Mr. Brady only after attempting to resolve your issue following the escalation protocol provided above.

When initially enacted on December 29, 2007, the enforcement clause under 42 U.S.C. §1395y(b)(8)(E) announced that applicable plans “shall be subject to a civil money penalty of $1,000 for each day of noncompliance with respect to each claimant.” That clause was changed with the SMART Act amendment to the MSP on January 10, 2013, effective at the beginning of 2014, to the phrase “may be subject to a civil money penalty of up to $1,000 for each day of noncompliance with respect to each claimant.” In this same 2013 SMART Act MSP amendment, an additional paragraph was added requiring the Secretary of the U.S. Department of Health and Human Services (Secretary) to publish a notice in the Federal Register soliciting proposals during a 60-day period, specifying practices by which enforcement sanctions would or would not be imposed under subparagraph (E). After proposals were to be submitted and considered, the Secretary, in consultation with the Attorney General, and after a 60-day comment period, was to publish in the Federal Register proposed specified practices for which enforcement sanctions will and will not be imposed and to later issue final rules specifying applicable enforcement practices. About a year after the SMART Act amendment was enacted, CMS sought comment through an advanced notice of proposed rulemaking (ANPRM) for the types of practices that would or would not result in civil money penalties, along with other related questions.  Final rules have still not been announced.

CMS wants “clean data” to be reported through Section 111 and has a process in place to test and reject reporting that does not meet CMS’ data quality rules.  How and when penalties for noncompliance with Section 111 will really be enforced will likely not be answered until CMS, through the Secretary of HHS, takes the required regulatory steps of issuing final rules on the subject.  Therefore, while most insurance companies and TPAs have set up internal systems to comply with Section 111, or paired with reporting agent vendors to help them comply, there is still time for Responsible Reporting Entities to establish a system to report Section 111 data without fear of reprisal.

Interestingly, another SMART Act initiative is now in its final stages of completion.  That initiative has been the gradual removal of Social Security Numbers from Medicare ID numbers through the replacement of the SSN-based Health Insurance Claim Number (HICN) with a new non-SSN-based Medicare Beneficiary Identifier (MBI).  CMS has estimated this project to be completed by April 2019.  It has mailed almost 35 million new Medicare cards to date with a majority of seven total “waves” of mailing completed. Will CMS begin tackling the reporting conundrum next? While companies doing reporting may still use the HICN and are not yet required to use the MBI in Section 111 Reporting, it would be wise for companies to plan ahead and ready themselves for transmission of the new MBI format Medicare ID in the future.


[1] Entities in the NGHP category include Liability Insurance (including Self-Insureds), Workers Compensation Plans, and No-Fault Insurance.

[2] 42 U.S.C. § 1395y(b)(2) et seq.

[3] SCHIP stands for State Children’s Health Insurance Program

[4] Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) (P.L. 110-173, Title I, §111(a)), found within the MSP at 42 U.S.C. § 1395y(b)(8).

 

CMS Revises Mandatory Insurer Reporting Implementation Timetable

 

On June 20, 2012, the Centers for Medicare and Medicaid Services issued three alerts revising the implementation timetable for the Medicare Secondary Payer (MSP) Mandatory Insurer Reporting (MIR) requirements.

The implementation timetable for liability TPOCs was revised as follows:

 

Mandatory Thresholds for Liability Insurance (including self-insurance) TPOC Settlements, Judgments, Awards or Other Payments

Total TPOC Amount TPOC Date On or After Section 111 Reporting
Required in the Quarter
Beginning
TPOCs over $100,000 October 1, 2011 January 1, 2012
TPOCs over $50,000 April 1, 2012 July 1, 2012
TPOCs over $25,000 July 1, 2012 October 1, 2012
TPOCs over $5,000 October 1, 2012 January 1, 2013
TPOCs over $2,000 October 1, 2013 January 1, 2014
TPOCs over $300 October 1, 2014 January 1, 2015

 

The implementation timetable for workers compensation TPOCs was revised as follows:

 

Mandatory Thresholds for Workers’ Compensation
TPOC Settlements, Judgments, Awards or Other Payments

Total TPOC Amount TPOC Date On or After Section 111 Reporting
Required in the Quarter
Beginning
TPOCs over $5,000 October 1, 2010 January 1, 2011
TPOCs over $2,000 October 1, 2013 January 1, 2014
TPOCs over $300 October 1, 2014 January 1, 2015

 

In addition, the mandatory minimum dollar threshold for workers’ compensation Ongoing Responsibility for Medicals (ORMs) for “medicals only” claims of $750 or less was extended indefinitely.  Previously this exemption expired on 12/31/2012.

It is important to note from that, beginning July 1, 2012, liability insurance TPOCs over $50,000 must be reported.

To view all three June 20, 2012 CMS Alerts click here.

 

 

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CMS Extends Section 111 Reporting Deadline and Dollar Thresholds

The Centers for Medicaid and Medicare Services (CMS) just announced another extension of the reporting deadline for the Medicare Secondary Payer (MSP) Mandatory Insurer Reporting (MIR) provisions in Section 111 of the Medicare, Medicaid, and SCHIP Extension Act (MMSEA) of 2007.   In an Alert dated November 9, 2010, CMS announced the following three timetable extensions.

TPOC Reporting Date changed to Q1, 2012 for Liability Insurance
The required submission date for liability insurance Total Payment Obligation to Claimant (TPOC) initial reports have been changed from the first calendar quarter of 2011 to the first calendar quarter of 2012.  TPOC refers to the dollar amount of a settlement, judgment, award or other payment intended to resolve or partially resolve a claim.

TPOC Capture Date changed to 10/1/2011 for Liability Insurance
The current rule requiring reporting on Non Group Health Plan (NGHP) TPOC dates starting on 10/01/2010 has been changed to 10/01/2011.

Dollar Threshold Dates are Extended One Year for both Liability and Workers’ Compensation Insurance
All dollar threshold dates for liability insurance and workers’ compensation have been extended by one year.  The new thresholds are as follows:

  • TPOC dates prior to 1/1/2013, with TPOC amounts of $0.00-$5,000.00, are exempt from reporting.
  • TPOC dates from 1/1/2013 through 12/31/2013, with TPOC amounts of $0.00 to $2,000.00, are exempt from reporting.
  • TPOC dates from 1/1/2014 through 12/31/2014, with TPOC amounts of $0.00 to $600.00, are exempt from reporting.
  • No threshold applies for TPOC dates on or after 1/1/2015.

It is important to note that this delay only applies to liability insurance reporting of TPOCs and dollar threshold dates for both liability and workers’ compensation insurance. Ongoing Responsibility for Medicals (ORM) reporting remains the same. Also, although the deadline has changed, early reporting is welcome, encouraged and will be accepted.

View the Alert here

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CMS Announces Direct Data Entry Option

The Centers for Medicare and Medicaid Services (CMS) recently announced a more effective reporting option for “small reporting” Responsible Reporting Entities (RREs).  This new method, referred to as the Direct Data Entry (DDE) Option, is only available for those RREs who will be reporting 500 or fewer claim reports per calendar year.

Those RREs that are able to utilize this DDE Option will be able manually enter and submit their data rather than submit an electronic file over the Section 111 Coordination of Benefits Secure Website (COBSW).  Small reporters may register for DDE as a reporting option beginning October 1, 2010.  If an RRE has already registered under the current methods, the Account Manager for the RRE will be able to change their reporting method on or after October 4, 2010.  These small reporters will be able to begin reporting using this DDE option on January 3, 2011.

The CMS goes on to state that there will be no testing period required for RREs using the DDE option, and claim information should be submitted one claim at a time “as soon as conditions related to the claim require reporting under Section 111.”  Also, those small reporters using the query system should be aware that if an injured party’s information does not match up to a Medicare beneficiary during the DDE process, it WILL count toward the RREs limit of 500 claims per year.

It is important to note that RREs utilizing the DDE option have the same responsibilities as any other RREs.  While this does provide an easier alternative for those RREs that have a very limited number of claims to support, those RREs that are borderline should take precautions to assure that they do not exceed the 500 claims per year limit.

To view this latest memo in its entirety, please click here.

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The CMS Again Delays Section 111 MIR Implementation Deadline

The Centers for Medicare and Medicaid Services (CMS) has once again delayed the final implementation deadline for Section 111 Mandatory Insurer Reporting (MIR) compliance. On February 16, 2010, the CMS advised all Non-Group Health Plan Responsible Reporting Entities (NGHP RREs) that the date for first production NGHP Input Files has been changed from April 1, 2010 to January 1, 2011.

The notice went on to state that testing of NGHP file data exchange will continue and all testing will be completed by December 31, 2010. It also stated that all NGHP RREs should now be registered with the COBC and either participating in or preparing for file testing status. The CMS is encouraging those NGHP RREs that have completed data exchange testing to proceed to production file data exchange status.

The notice advised that the next version of the NGHP User Guide will be posted on the CMS website during the week of February 22, 2010. An alert is also forthcoming that will list the necessary steps NGHP RREs can take to assure their compliance with Section 111 reporting requirements.

To view this latest alert in its entirety, please click here.

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Trade Groups Ask HHS to Delay MSP Reporting Requirement Deadline

Three insurer trade organizations have sent a joint letter to the Secretary of Health and Human Services, Kathleen Sebelius, seeking to extend the April 1, 2010 implementation of the Medicare Secondary Payer (MSP) mandatory insurer reporting (MIR) requirement. This letter outlines five major reasons as to why the Department of Health and Human Services should consider extending the deadline:

  1. Reporting Guidance: the Centers for Medicare and Medicaid Services (CMS) has yet to issue final guidance on some issues.
  2. Collection of Social Security Numbers (SSN) or Health Insurance Claim Numbers (HICN): insurance and self-insured companies are concerned about the inability to obtain critical data elements such as SSNs or HICNs.
  3. Confidentiality and Security of the Data: there are still serious concerns that the CMS is not using the most effective security and encryption technology to ensure the data submitted is properly secured.
  4. Inadequate testing period: there are concerns that the testing period CMS used was too short for required reporting entities (RREs) and CMS to properly ensure that their systems were operational prior to the reporting deadline.
  5. Penalties: there is a belief that the $1000 per day, per claim penalty is excessive. There is further belief that this penalty should not be enforced on the initial reports submitted by RREs.

If successful, this would represent the third extension since Section 111 of the Medicare, Medicaid, SCHIP Extension Act of 2007 (MMSEA) first called for MIR compliance.

To read the letter in its entirety, please click here.

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CMS Releases Reference Guide for Section 111 Registration

On May 8, 2009, The Centers for Medicare and Medicaid Services (CMS) released a quick reference guide for Section 111 registration for all Responsible Reporting Entities (RREs). Included within this guide are examples of issues a registrant may encounter when trying to register, such as how to obtain an RRE ID number, and how to register multiple RRE IDs.

Also included with this reference guide are useful web links to Section 111 Mandatory Insurer Reporting pages within the CMS website.

To view this guide, please click here.

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CMS Updates Section 111 Implementation Timeline

On May 11, 2009, The Centers for Medicare and Medicaid Services (CMS) announced several changes relating to Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA). These changes include an update to the implementation timeline, as well as updates on reporting thresholds for Total Payment Obligations to Claimants, or TPOCs.

With the release of this memo, the registration period for liability insurance (including self-insurance, no-fault insurance, and workers’ compensation RREs) has been extended. RREs now have from May 1, 2009 through September 30, 2009 to register. Consequently the testing period will now take place from January 1, 2010 through March 31, 2010, with first live files now scheduled to be submitted in the April-June quarter of 2010.

There have also been some changes relating to the TPOCs. The CMS has now determined that the Section 111 reporting will not include the reporting of TPOC amounts with dates prior to January 1, 2010. If a TPOC amount dated on or after January 1, 2010 falls below the threshold amount, the RRE is to add all associated TPOC amounts dated on or after January 1, 2010 in determining if the reporting threshold is met. Any associated TPOC amount occurring prior to January 1, 2010 should not be considered when calculating the TPOC amount for purposes of the reporting threshold. However, The CMS has also stated within this memo that although RREs are not required to report TPOCs where the applicable TPOC date is prior to January 1, 2010, a record will not be rejected based upon a TPOC date before January 1, 2010.

To view this memo in its entirety, please click here.

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CMS Releases Reference Guide for Section 111 Registration

On May 8, 2009, The Centers for Medicare and Medicaid Services (CMS) released a quick reference guide for Section 111 registration for all Responsible Reporting Entities (RREs). Included within this guide are examples of issues a registrant may encounter when trying to register, such as how to obtain an RRE ID number, and how to register multiple RRE IDs.

Also included with this reference guide are useful web links to Section 111 Mandatory Insurer Reporting pages within the CMS website.

To view this guide, please click here.

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CMS Further Clarifies “Delete Record” Issues

CMS has attempted to further clarify some of the issues surrounding the pending reporting requirements set forth in Section 111 of the MMSEA. These new clarifications have undoubtedly resulted from issues raised during the registration and testing period for GHP RREs, which began earlier this month.

First of all CMS has brought attention to Deleting Records. They have updated their website to stress that the “Delete Record” function should ONLY be used for the following circumstances:

1. To delete an entire record that was created in error.

For example, if a record was created and posted (you received a ’01’ disposition code in your MSP Response File) and it never should have been created, a Delete would be used to remove the record. CMS goes on to say that if you submitted a file in error but never received a “01”, than there is no need to submit a “Delete Record” for that file.

2. To correct one of the following key fields in a previously successfully added MSP record: Effective Date, Insurance Coverage Type, and Patient Relationship. In these cases the Delete should be followed by an Add transaction containing the correct information.

CMS goes on to say that if other information changes, (for example, Termination Date), than the RRE is to follow standard Update procedures. Additional updates today include the posting of the transcripts from the April 8, 2009 GHP Town Hall Meeting and the April 9, 2009 Non-GHP Town Hall Meeting. They have also added the COBSW link to their Overview section of the CMS website. To view these updates in their entirety, please click here.

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CMS Memo Updates TPOC Reporting

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.

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CMS Opportunity to Comment

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:

PL110-173SEC111-comments@cms.hhs.gov

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.

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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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CMS Posts Section 111 User Guide Version 1.0

The Centers for Medicare and Medicaid Services (CMS) has posted its highly anticipated User Guide, which outlines how RREs are to handle their reporting responsibilities. This guide will serve as CMS’ first attempt to clarify the issues surrounding the reporting requirements brought forth by Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA). As the title of this guide suggests, there will certainly be updates and new versions as we approach the implementation deadline. To view or download this guide, please click here.