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Medicare Secondary Payer Section 111 Reporting – Top 10 Issues for Companies and Agents.

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Presentation on theme: "Medicare Secondary Payer Section 111 Reporting – Top 10 Issues for Companies and Agents."— Presentation transcript:

1 Medicare Secondary Payer Section 111 Reporting – Top 10 Issues for Companies and Agents

2 2 Medicare Secondary Payer – Section 111 Issues in Medicare Secondary Payer Reporting John Giknis, CPCU, SCLA, RPA, AIC Assistant Vice President ISO ClaimSearch Operations

3 3 Medicare Secondary Payer – Section 111 Requirements The Medicare Secondary Payer legislation, section 111, requires insurers and self insurers (Responsible Reporting Entities) to report all claims involving Medicare- eligible claimants to the Center for Medicare and Medicaid Services (CMS). Companies must register as an RRE with CMS prior to reporting. Lines of business include Workers Comp, Liability and No-Fault claims, considered “Non-Group Health Plan” (NGHP). Quarterly reporting involves all Medicare-eligible claimants – Recurring payments (WC and no-fault): report at first payment or acceptance of coverage and at end of “ongoing payment responsibility” (ORM) – Single payment liability claims: report only at settlement, judgment or award by Total Payment Obligation to the Claimant (TPOC) date

4 4 1.The RRE Determination – Who/What is the RRE? Insurer Self Insurer Self-insured Pool – How many RRE’s are needed? 2.The CMS Registration Process – Group vs. Affiliates and Subsidiaries – TIN and Entity Name must be compatible – Selection of Agent – or direct reporting – Account Manager selection “Invite” account designees Medicare Secondary Payer – Section 111 Issues

5 5 3.How to determine if the claimant is a Medicare recipient (beneficiary) – Claimant is 65 or over – Claimant is under 65, but qualifies for Medicare – Use the CMS Query 4.Complication from CMS Reporting Requirements – IT resources – Availability of data: SSN/DOB – Training staff on unfamiliar reporting elements – Obtaining information from archived files – Issues “under consideration” – Reporting periods – Thresholds Medicare Secondary Payer – Section 111 Issues

6 6 5.Determining Reporting Types – Ongoing Responsibility for Medicals (ORM) – Total Payment Obliga tion to Claimant (TPOC) 6.Quarterly Reporting – Reporting period (per RRE) – Separate file for acknowledgments/ rejections – Return results to company claims systems 7.Query Process – Same RRE issues – One file per RRE per month – Which claims (claimants ) to query – When to stop querying – Required fields: how to identify in history files Medicare Secondary Payer – Section 111 Issues

7 7 8.Rejections – Rejection file per RRE – How to identify prior to submission to CMS – How to correct and return – timing 9.CMS Communications/Direction – Changes in requirements, thresholds and timing – Issues “taken under advisement” 10. Indemnification Issues Medicare Secondary Payer – Section 111 Issues

8 8 Medicare Secondary Payer – Section 111 Additional information on the ISO ClaimSearch Medicare Secondary Payer, Section 111 service – For more information or requests, please – Overview and training documents available on the ISO CMS website:


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