What claims are Section 111 reportable, and when are they to be reported?

January 29, 2019

There are multiple factors to consider when determining if a claim is reportable and when it should be reported to Medicare. In fact, CMS published nearly 4000 words on this topic in chapter 3, section 6.5.1 of the NGHP User Guide. In an attempt to provide you with the “basics” in a more palatable manner, we are publishing this article.

CMS’ answer to the question “what claims are reportable” is as follows: “Information is to be reported for claims related to liability insurance (including self-insurance), no-fault insurance, and workers’ compensation where the injured party is (or was) a Medicare beneficiary and medicals are claimed and/or released or the settlement, judgment, award,or other payment has the effect of releasing medicals.”

Out of CMS’ definition of “what claims are reportable,” we can deduce two things.

  1.        Only claims involving a Medicare beneficiary are reportable; and
  2.        Claims involving Medicare beneficiaries are only reportable once a reportable event occurs.

Item number one was covered in a previous article titled “How do I know who is Medicare eligible.” That article can be found (here). For this article, we will focus on the reportable events that need to be reported to CMS. There are two primary events that qualify a claim for reporting, Ongoing Responsibility for Medical (ORM), and Total Payment Obligation to Claimant (TPOC). For ORM, we will need to cover both the establishment of ORM and the Termination of ORM. Similarly, we will split TPOC into TPOC Amount and TPOC Date.

Let us first start with On Going Responsibility for Medical (ORM). ORM means an RRE has “presently assumed” an obligation to pay for an injured party’s medicals associated with the Work Comp, Liability, or No-Fault claim. Payments do not have to be made for the ORM to be accepted. ORM is established, “when the RRE has made a determination to assume responsibility for ORM, or is otherwise required to assume ORM.” Once you have confirmed ORM is assumed on a claim, you will need to confirm the effective date for the ORM in order to determine if the claim is or is not reportable. If the ORM effective date is on or after 1/1/2010, it is a reportable event.

Termination of ORM is another reportable event. Once the ORM has ended, an RRE needs to report the date of termination to CMS. CMS provides the following criteria defining ORM Termination:

  • Where there is no practical likelihood of associated future medical treatment, the RRE may submit a termination date for ORM if it maintains a statement (hard copy or electronic) signed by the beneficiary’s treating  physician that no additional medical items and/or services associated with the claimed injuries will be required.  In layman’s terms this means if there is a doctor’s note indicating that no further treatment is required.
  • Where the insurer’s responsibility for ORM has been terminated under applicable state law associated with the insurance contract.  In layman’s terms, this means statute of limitations, claim denial, settlement or some other action occurs to demonstrating that the RRE is no longer legally responsible to pay for medical treatment.
  • Where the insurer’s responsibility for ORM has been terminated per the terms of the pertinent insurance contract, such as maximum coverage benefits.  In layman’s terms, this means policy limits have been hit or the policy term has exhausted.

The termination of ORM must be reported within 135 days of the Termination Date in order to avoid a compliance flag for late reporting. 

The other primary reportable event is the occurrence of a Total Payment Obligation to Claimant (TPOC). CMS defines TPOC as, “a settlement, judgement, award, or other payment in addition to or apart from ORM . . .” that is intended to resolve or partially resolve a claim. The TPOC Amount will be the total obligation of the settlement, judgment, award, or other payment. For example, if an annuity is used to fund the settlement, the TPOC will be the total amount of the settlement agreement. It will not be just the annuity seed money. 

The current TPOC low-dollar threshold for 2019 is $750.00, so any settlement greater than this amount is reportable[1]. In addition to reporting the TPOC Amount, the TPOC Date will need to be reported. The TPOC Date is the date the payment obligation was established. This will be the date the settlement documents are signed. If court approval is required, the TPOC Date will be the date the court approves the settlement. If there is no settlement agreement, the TPOC Date is the date the payment is issued. Like the ORM Termination, the TPOC must be reported within 135 days of the TPOC Date to avoid a compliance flag for late reporting. 

As stated in the opening of this article, this is just a condensed version of CMS’ requirements. Moreover, MMSEA Section 111 Reporting is complex and requires coordination between claims operations, IT departments and executive leadership.  Substantial issues can arise if reporting falls short both internally (in the form of inefficiency and added cost) and externally (in the form of possible civil money penalties of up to $1,000 per day per claim).  If your organization is involved with claims having a medical component, whether directly responsible or not, you may be required to participate in MMSEA Section 111 Reporting.   If you have any questions about the reporting process or need assistance determining if you have an obligation to report, please contact us at MIRService.Support@examworkscompliance.com.

[1] Settlements beneath that amount are exempt from the Medicare Secondary Payer guidelines.