RREs Must Report Combined Med Pay and PIP Coverage Limits on No-Fault Claims

June 28, 2020

On June 8, 2020, the Centers for Medicare & Medicaid Services (CMS) issued an alert to remind non-group health plan (NGHP) responsible reporting entities (RREs) that they must combine both Med Pay and personal injury protection (PIP) coverage limits when reporting claims to CMS via Section 111 mandatory insurer reporting. While Med Pay and PIP are separate coverages to be paid out on claims, CMS requires RREs to report the combined total of both coverage limits for a no-fault claim involving the same injured party and stemming from the same incident.

For example, if a policy provides a $5,000 limit for Med Pay and a $10,000 limit for PIP benefits, then the no-fault case is reported to CMS with ongoing responsibility for medicals (ORM). If we assume the injured party actively treats prior to the expiration of any policy time limit and / or statute of limitations, then ORM terminates when $15,000 in coverage is appropriately exhausted.

CMS issued the alert because they have found that “some NGHP RREs are only including Med Pay when reporting the No-Fault Insurance Limit. If both Med Pay and PIP coverage limits are not reported, then the amount reported is not an accurate reflection of the policy limit. Ongoing Responsibility for Medicals should not terminate until both the Med Pay and PIP coverage limits are exhausted.”

CMS also used the alert to remind RREs to “accurately reflect two decimal places when reporting No-Fault Insurance Limit. For example, a policy limit of $5,000 should be reported as 500000.”

This alert, coming so close on the heels of the proposed rule for imposing civil monetary penalties, is one to heed as you continue to work to ensure full Section 111 compliance prior to enactment of any final rule. ECS is following this closely and no date has been set yet for the release of any final rule. We have the largest and most experienced team of Section 111 reporting experts in the country. With the looming threat of a final rule on civil money penalties, please reach out to our team to check on your existing Section 111 reporting process. If you have an obligation to report but have not yet registered – do not delay. Contact our Mandatory Insurer Reporting Team at MIRService.Support@examworks-cs.com or 678-222-5454 to schedule an evaluation today.

Annie M. Davidson

Annie M. Davidson

Annie M. Davidson is the Vice President of Client Success for ECS. In her role, Annie works collaboratively with clients, industry partners, and leaders at all levels to identify and execute on short-term and long-term goals and consistently exceed expectations. Prior to joining ECS, Annie practiced as an insurance defense attorney in her native Minnesota where she litigated workers’ compensation and liability insurance cases, particularly those involving MSP issues. She is admitted to practice law in the State of Minnesota and the United States District Court for Minnesota, and is a graduate of William Mitchell College of Law. Annie can be reached at annie.davidson@examworkscompliance.com or at 651-262-9618.