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Translating CMS Terminology for your Claims Department And How to translate your children’s text messages. VISIONS FOR THE FUTURE.

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Presentation on theme: "Translating CMS Terminology for your Claims Department And How to translate your children’s text messages. VISIONS FOR THE FUTURE."— Presentation transcript:

1 Translating CMS Terminology for your Claims Department And How to translate your children’s text messages. VISIONS FOR THE FUTURE

2 Imposed through Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) Medicare Secondary Payer Mandatory Reporting

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4 Protecting Medicare’s Interests  Medicare is always secondary to workers compensation insurance.  Future medical payments are protected by Medicare Set-Aside arrangements (2001).  Past payments are covered by this new reporting so that Medicare can recover any $$$ it paid that we should have paid.

5 Conditional (Past) Payments made by CMS  Mandatory quarterly reporting of all Medicare eligible claimants on the issues of:  ORM  TPOCs  Provides CMS the ability to query their files and determine if they paid something that a primary payer should have paid.

6 Conditional (Past) Payments made by CMS  Mandatory quarterly reporting of all Medicare eligible claimants on the issues of:  Ongoing responsibility for medicals (ORM)  Total payment obligation to claimants (TPOCs)  Provides CMS the ability to query their files and determine if they paid something that a primary payer should have paid.

7 Text Translations  411  511  AYS  AYT  MOS  LEMENO

8 Who must report? RRE

9 Who must report?  The Responsible Reporting Entity for a claim (including but not limited to):  The insurance carrier where there is policy coverage.  The self-insured entity where the SI makes payments directly to the claimant.  The excess or reinsurance carrier where the carrier makes payments directly to the claimant. http://www.cms.gov/MandatoryInsRep/Downloads/ AlertWhoMustReportrev052610.pdf

10 Medicare Reporting Process  Monthly query file to determine which of our claimants are Medicare eligible.  SSN or HICN: REQUIRED  First initial  Last name (6 characters)  DOB  Gender

11 Medicare Reporting Process  Quarterly reporting of data on Medicare eligible claimants  Where ongoing responsibility for medicals exists as of Jan 1, 2010  On claims with settlements, judgments or awards on/after October 1, 2010.

12 Text Translations  LMBO  ROTFLMBO

13 Penalties for Non-Compliance  Failure by a Responsible Reporting Entity (RRE) to timely report a claim to CMS has a penalty payment of $1000 per day per claim.  Penalty collections have already been allocated to the SCHIP program.

14 Text Translations  NOYB  BFF  BFFNMW  CD9  CM

15 Challenges/Translations/Training  Missing SSN or DOB  Date of accident for Occupational Diseases  Flagging TPOCs  Date of a TPOC  Settlement for solidary obligors  ICD-9 Coding (covered/alleged/released)  Denied Claims  RPO Claims

16 Missing SSN or DOBs  At claim intake?  During the claim investigation.  Form recommended by CMS.  Documentation in the claims file. http://www.cms.gov/MandatoryInsRep/Downloads/NG HHICNSSNNGHPForm.pdf

17 Date of Accident for Occupational Diseases  Identifying OD claims and CT claims.  Date of last injurious exposure is the date of accident in LA.  CMS: Date of first exposure  After the date of Medicare eligibility (which they won’t give us)  Which could be with a different employer, with no obligation to us, insured by another carrier….

18 Text Translations  OTP  DBEYR  DGT  EOD  RUMOF

19 Flagging TPOCs  Payments to the claimant (but not all payments)  Settlements, judgment, award, or other payment in addition to/apart from ORM.  Structured settlement (total payout from the annuity).  Identify by Payment Codes?

20 TPOC Dates  Defined in Field 100 of the Claim Input File Detail Record.  Date payment obligation was signed if court approval not required (not necessarily the date of the check).  Date of court approval (on judgments and consent judgments).  Do you have these dates in your claims system?

21 TPOCs and Injuries Covered, Alleged, or Released.  New to User Guide 3.1  When claims are settled, ICD-9 coding must cover any injuries covered, alleged, or released.  Who tracks injuries alleged? http://www.cms.gov/MandatoryInsRep/Downloads/NG HPUserGuideV3.1.pdf

22 Settlement for Solidary Obligors  Seriously? Really?  Report the total amount of the settlement paid by all parties.  Even though you don’t have that payment info in your system, and you are not issuing those checks.  In LA: Borrowing employer or direct/statutory employer situation where the settlement is partially funded by another employer/insurer.

23 Text Translations  GL2U  GTG  SUP  IDK  JK

24 ICD-9 Coding For Claims with ORM  One ICD-9 code, per covered body part, up to 5. After 5, provide the codes if they are available/applicable (up to 19).  For 1/1/11 reporting, CMS will accept Versions 27, 28, & 29.  Training…..  Conversions to ICD-10 and training down the line.

25 ICD-9 Coding For Claims with TPOCs  One ICD-9 code, per covered, alleged, or released body part, up to 5. After 5, provide the codes if they are available/applicable (up to 19).

26 Denied Claims  ORM = No, right? Wrong.  Paying initial medical treatment without an admission of liability.  Paying for an evaluation because your statute requires it.  CMS will assume ORM from date of accident until the ORM term date.

27 RPO (Reporting Purposes Only) or Incident Only Claims  Notice of the claim  Carrier must have notice to query the file.  The employer assumes responsibility as the RRE if they are paying the claim and do not report.  Clmt (65) reports a knee injury to employer, but does not seek medical care immediately. Claim is submitted to carrier as an RPO. Is this okay? The employee sees the doctor a week later and files with Medicare. Is this okay?

28 Text Translations  BBL  BBIAM  L8R  L8RG8R  MTFBWU

29 Thank you!

30 Jill Breard Director of RMS Operations LWCC (225) 231-0805 jbreard@lwcc.com


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