Section 111 Mandatory Insurer Reporting is a cornerstone of Medicare Secondary Payer (MSP) compliance, yet it remains an area where confusion persists - even among experienced claims professionals. One of the most prevalent misconceptions is the belief that Medicare eligibility alone automatically triggers a Section 111 reporting obligation.
Let’s begin by clarifying a few general terms, in that an individual can be eligible for Medicare but not be a Medicare beneficiary. Medicare eligibility only means that the individual has the ability to enroll, whereas a Medicare beneficiary refers to an individual that is actively enrolled and receiving benefits. There are several factors that would allow for an individual to be Medicare eligible, including age, disability status, etc. In CMS’ eyes, individuals that are Medicare eligible or are Medicare beneficiaries would fall into the same category - where Medicare’s interests should be considered.
Digging deeper, Medicare eligibility is only one piece of a larger compliance framework. Understanding what does, and does not, trigger Section 111 reporting is critical to avoiding unnecessary reporting, preventing data errors, and reducing downstream compliance risk.
Understanding the Purpose of Section 111 Reporting
Section 111 of the Medicare, Medicaid, and SCHIP Extension Act (MMSEA) requires Responsible Reporting Entities (RREs) to report certain workers’ compensation and liability claim information to the Centers for Medicare & Medicaid Services (CMS). The purpose of this reporting is to allow Medicare to determine when it should be the secondary payer, rather than the primary payer, for medical expenses related to an injury or claim.
In short, Section 111 reporting is event-driven, not status-driven. CMS is not asking insurers to report every Medicare-eligible individual that they are aware of - only those claims where specific reporting criteria are met.
The Role of the Query Process
Medicare provides RREs with an electronic query process, allowing companies to check Medicare status on large volumes of claims on a monthly basis. As part of the information exchanged and provided, Medicare includes enrollment information (e.g. Medicare Part A effective date) as well as termination date(s) for Medicare enrollment. Thus, in many cases, it would be possible to identify and track a beneficiary’s status based on the query data.
It’s worth noting, however, that a person’s Medicare eligibility status as returned in the query file is point-in-time. Best practices, especially for individuals who are currently eligible for Medicare but not yet enrolled, are to report their claim data to CMS if a triggering event occurs. This ensures that civil money penalties will not be applied and the RRE could receive a “03” response in the Section 111 file signifying that “the injured party was matched to a Medicare beneficiary, but the period of time reflected on the claim report did not overlap the beneficiary’s Medicare coverage dates.”
Medicare Eligibility Alone Is Not a Reporting Trigger
A claimant’s Medicare eligibility—whether due to age, disability, or end-stage renal disease—does not, by itself, create a Section 111 reporting obligation.
Instead, reporting is required only when both of the following conditions are present:
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The individual is a Medicare beneficiary, and
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A reportable event has occurred, such as:
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The acceptance or ongoing responsibility for medicals (ORM), or
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A Total Payment Obligation to the Claimant (TPOC), such as a settlement, judgment, or award.
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Accordingly, absent a reportable ORM or TPOC event, Medicare eligibility alone does not require reporting.
ORM and TPOC: The True Reporting Triggers
To fully understand Section 111 obligations, it’s essential to distinguish between ORM and TPOC:
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Ongoing Responsibility for Medicals (ORM) refers to situations where an insurer has accepted responsibility to pay for ongoing medical treatment related to a claim.
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Total Payment Obligation to the Claimant (TPOC) refers to a payment or award resolving all or part of a claim, such as a settlement.
If an insurer has not accepted ORM and no TPOC has occurred, there is generally nothing to report, even if the claimant is Medicare eligible. This distinction is often misunderstood and can lead to over-reporting or inaccurate submissions.
Why This Misconception Persists
Several factors contribute to ongoing confusion around Medicare eligibility and Section 111 reporting:
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Risk aversion: Claims teams may assume “better safe than sorry” when Medicare is involved, especially in a climate where Civil Money Penalties for non-compliance is now being enforced.
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Complex CMS guidance: While extensive, CMS guidance can be difficult to interpret in real-world claim scenarios.
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Automation without context: Medicare eligibility may be flagged without fully evaluating whether a reportable event exists.
While caution is understandable, unnecessary reporting can create its own problems, including inaccurate CMS records, rejected submissions, and additional administrative burden.
The Risks of Over-Reporting
Over-reporting can be just as problematic as under-reporting. Submitting records when no reporting obligation exists may result in:
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Erroneous CMS data linking Medicare payments to unrelated claims
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Increased risk of conditional payment disputes
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Claim delays caused by unnecessary compliance steps
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Additional scrutiny during audits or data validation processes
Accurate Section 111 reporting requires not only identifying Medicare beneficiaries but also applying CMS rules correctly and consistently.
Best Practices for Getting It Right
To avoid common reporting mistakes, insurers and TPAs should consider the following best practices:
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Evaluate the claim, not just the claimant. Medicare status must be analyzed in conjunction with ORM and TPOC activity.
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Document reporting decisions. Clear documentation supports defensibility if reporting determinations are later questioned.
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Use expertise, not assumptions. MSP compliance decisions should be guided by CMS rules - not fear of penalties.
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Coordinate Section 111 reporting with settlement strategy. Reporting should align with lien resolution, MSAs, and claim closure planning.
Final Thoughts
Medicare eligibility is an important factor in MSP compliance, but it is not an automatic trigger for Section 111 reporting. Understanding when reporting is actually required allows insurers to remain compliant while avoiding unnecessary administrative burden and risk.
As CMS continues to refine its reporting expectations and enforcement efforts, clarity and precision in Section 111 reporting are more important than ever. Ensuring that reporting decisions are driven by facts, events, and CMS guidance—not misconceptions—helps protect both claim outcomes and organizational integrity.
With deep MSP expertise and industry-leading technology, ECS supports RREs in navigating Section 111 reporting with confidence. Should you have any questions please contact your local ECS regional compliance consultant, ECS MIR Service Support, or the ECS Compliance Team at mspcompliance@examworkscompliance.com.
