Gould & Lamb MMSEA Field Review for the Lloyd’s Market May 2011 Revised 22-Sep-2011

Field Types Required Situational Optional Fields must be present for CMS and/or G&L processing. Regardless of Plan Type or fact pattern of the claim. Situational Fields may be required for CMS and/or G&L processing. Dependent on Plan Type and/or fact pattern of the claim. May be required conditionally on population of other fields. Optional Not required for processing by CMS and/or G&L. May or may not be utilized by CMS. Allows for provision of additional information, if present.

Detailed Field Review The following fields are required in both the Customer Claim Input and Customer Claim Eligibility file types in order to create and update claim records in MIRService

Fields to Determine Eligibility Section 111 RRE ID: Required Responsible Reporting Entity Identifier Identification number assigned by CMS to the Lloyd’s Syndicate at the time of registration

Fields to Determine Eligibility ICN Required Internal Control Number A unique and non-changing record identifier Assigned by the Lloyd’s Market Managing Agent, Coverholder, TPA or Attorney May be a claim number if the same remains unique throughout the life of the claim

Fields to Determine Eligibility Injured Party HICN Situational: required if SSN not provided Number assigned to the Injured Party by CMS when they become Medicare Eligible Fill with spaces if unknown and SSN provided Do not include dashes

Fields to Determine Eligibility Injured Party SSN Required by G&L for processing Situational: required if HICN is not provided. Number assigned to the Injured Party by the Social Security Administration Fill with spaces if unknown and HICN provided Do not include dashes

Fields to Determine Eligibility Injured Party Last Name Required Surname of the Injured Party as it appears on the individuals Social Security or Medicare Insurance Card Embedded hyphens (dashes), apostrophes and spaces accepted Injured Party First Name Given or first name of Injured Party as it appears on the individual's Social Security or Medicare Insurance card May not be a nickname or alias May only contain letters and spaces

Fields to Determine Eligibility Injured Party Gender Required Code which reflects the gender of the Injured Party Valid values: 0 = Unknown* 1 = Male 2 = Female Injured Party Date of Birth Date of Birth of the Injured Party Format: CCYYMMDD (example: 20110526 as today’s date)

Detailed Field Review The following fields may be required for population once the Injured Party has been identified as Medicare Eligible

Fields for Medicare Reporting Injured Party Middle Initial Optional First letter of the Injured Party’s middle name. Name should be as it appears on the individuals Social Security or Medicare insurance card. Fill with space if unknown

Fields for Medicare Reporting CMS Date of Incident Required First date of exposure, implantation, ingestion or traumatic injury Initially, this field may be populated with the Date of Accident but should be changed to the CMS Date of Incident once known Format: CCYYMMDD (example: 20110526 as today’s date) Liability claims; post 5-Dec-1980 Workers' Compensation claims; post 1-Jan-1965

Fields for Medicare Reporting Industry Date of Incident Optional Date of the accident. For claims involving exposure, ingestion, or implantation, the date of incidents the date of last exposure, ingestion, or implantation Industry DOI generally differs from the definition which CMS must use Format: CCYYMMDD (example: 20110526 as today’s date)

Fields for Medicare Reporting Alleged Cause of Injury, Incident or Illness; ICD-9 “eCode” Required International Classification of Diseases, Ninth Revision, Clinical Modification External Cause of Injury Code describing the alleged cause of injury/illness Must be on one of the most current lists/files of valid ICD-9 diagnosis codes accepted by CMS for Section 111 Must NOT be on the list of Excluded ICD-9 Diagnosis Codes found in Appendix H of the CMS NGHP User Guide Must begin with the letter ‘E’ Decimal points implied See , free ICD-9 code search tool: https://www.gouldandlamb.com/icd9-codes

Fields for Medicare Reporting ICD-9 Diagnosis Code 1 Required International Classification of Diseases, Ninth Revision, Clinical Modification Diagnosis Code describing the alleged injury/illness Must be on one of the most current lists/files of valid ICD-9 diagnosis codes accepted by CMS for Section 111 Must NOT be on the list of Excluded ICD-9 Diagnosis Codes found in Appendix I of the CMS NGHP User Guide No “E Codes” or “V Codes” permitted Decimal points implied See , free ICD-9 code search tool: https://www.gouldandlamb.com/icd9-codes

Fields for Medicare Reporting ICD-9 Diagnosis Code 2 through 19 Situational: required when multiple body parts are affected International Classification of Diseases, Ninth Revision, Clinical Modification Diagnosis Code describing the alleged injury/illness Must be on one of the most current lists/files of valid ICD-9 diagnosis codes accepted by CMS for Section 111 Must NOT be on the list of Excluded ICD-9 Diagnosis Codes found in Appendix I of the CMS NGHP User Guide No “E Codes” or “V Codes” permitted Decimal points implied See , free ICD-9 code search tool: https://www.gouldandlamb.com/icd9-codes

Fields for Medicare Reporting State of Venue Required The US state or territory in which the accident occurred or from which it is being adjudicated Valid value of US postal code abbreviations ‘US’ where the claim is a Federal Tort Act liability insurance matter or Federal Workers' Compensation claim ‘FC’ in cases where the state of venue is outside the United States

Fields for Medicare Reporting Claim Number Required The unique claim identifier by which the primary plan identifies the claim If liability self-insurance or workers’ compensation self-insurance, fill with zeroes if a specific number reference is not available or maintained

Fields for Medicare Reporting Self Insured Indicator Situational: required when the Plan Insurance Type is E (Workers' Compensation) or L (Liability) Indication of whether the reportable event involves self-insurance as defined by CMS* Valid values: Y = Yes N = No * Self-insurance rules applicable to Liability and WC do not apply to No-Fault, if Plan Insurance Type is D (No-Fault), then fill with a space or N

Fields for Medicare Reporting Self-Insured Type Situational: required if the Self Insured Indicator is Yes Valid Values: I = Individual O = Other than Individual (business, corporation or organization)

Fields for Medicare Reporting Policyholder Last Name Situational: required if the Self Insured Type is I (Individual) Surname of policyholder or self insured. Embedded hyphens (dashes), apostrophes and spaces accepted Policyholder First Name Given or first name of policyholder or self insured. May only contain letters and spaces

Fields for Medicare Reporting DBA Name Situational: required if Self Insured Type is O (Organization) and Legal Name is not provided “Doing Business As” name of self insured organization / business Legal Name Situational: required if Self Insured Type is O (Organization) and DBA Name is not provided. Legal name of self insured organization / business

Fields for Medicare Reporting Policy Number Required The unique identifier for the policy under which the underlying claim was filed RRE defined If liability self-insurance or workers compensation self-insurance, fill with zeroes if a specific number reference is not available or maintained

Fields for Medicare Reporting Plan Insurance Type Required Type of insurance coverage or line of business provided by the plan policy or self-insurance Valid values: D = No-Fault* E = Workers’ Compensation L = Liability * Per CFR 411.50: "No fault" insurance means insurance that pays for medical expenses for injuries sustained on the property or premises of the insured, or in the use, occupancy, or operation of an automobile, regardless of who may have been responsible for causing the accident. This insurance includes but is not limited to automobile, homeowners, and commercial plans. It is sometimes called 'medical payments coverage', 'personal injury protection', or 'medical expense coverage'.

Fields for Medicare Reporting No-Fault Insurance Limit Situational: required if Plan Insurance Type if ‘D’ (No-Fault) Dollar amount of limit on no-fault insurance Specify dollars and cents with implied decimal No formatting (no $ or , or .) Fill with all 9's if there is no dollar limit Fill with all 0's if Plan Insurance Type is E (Workers’ Compensation) or L (Liability Insurance - including Self-Insurance)

Fields for Medicare Reporting Exhaust Date for Dollar Limit for No-Fault Insurance Situational: required if Plan Insurance Type if ‘D’ (No-Fault) Date on which limit was reached or benefits exhausted for No-Fault Insurance Limit Fill with zeros if No-Fault limit has not been reached/exhausted or Plan Insurance Type is E (Workers’ Compensation) or L (Liability Insurance - including Self-Insurance) Format: CCYYMMDD (example: 20110526 as today’s date)

Fields for Medicare Reporting Required Federal Tax Identification Number of the "applicable plan" used by the RRE (Lloyd’s Syndicate) whether liability insurance (including self-insurance), no-fault insurance or a workers’ compensation law or plan In the case of an RRE not based in the United States and without a valid IRS-assigned TIN, a pseudo-TIN may be created by the RRE during the registration process Format 9999xxxxx where ‘xxxxx’ is any number of the RRE’s choosing

Fields for Medicare Reporting TIN/Office Code Mailing Name Required This name should reflect what should be used by Medicare to address correspondence to the RRE (Lloyd’s Syndicate) related to the associated claim reports. This is the name used for recovery demand notifications, if applicable

Fields for Medicare Reporting TIN/Office Code Mailing Address Line 1 Required This mailing address should reflect where the RRE wishes to have all correspondence (including correspondence associated with recoveries, if applicable) directed for the TIN/Office Code combination Must be a US address Street number and street name If the RRE has registered as a foreign entity and no US address is available, fill with spaces and supply "FC" in the TIN/Office Code State TIN/Office Code Mailing Address Line 2 Optional Second line of the address associated with the unique TIN/Office Code combination Other information such as suite number, attention to, etc

Fields for Medicare Reporting TIN/Office Code City Required City of the address associated with the unique TIN/Office Code combination Must be a US city If the RRE has registered as a foreign entity and no US address is available, fill with spaces and supply "FC" in the TIN/Office Code State TIN/Office Code State US Postal state abbreviation of the address associated with the unique TIN/Office Code combination If the RRE has registered as a foreign entity and no US address is available, supply "FC" and place the Foreign RRE Address 1 – 4 fields

Fields for Medicare Reporting TIN/Office Code Zip Required 5-digit Zip Code of the address associated with the unique TIN/Office Code combination reflected on this record Must be a US Zip Code If the RRE has registered as a foreign entity and no US address is available, fill with zeroes and supply "FC" in the TIN/Office Code State TIN/Office Code Zip+4 Optional 4-digit Zip+4 code of the address associated with the unique TIN/Office Code combination reflected on this record If not applicable fill with zeroes

Fields for Medicare Reporting Foreign RRE Address Line 1 Situational: required of the TIN/Office Code State = ‘FC’ First line of mailing address of a foreign RRE Use only if RRE has no US address

Fields for Medicare Reporting Foreign RRE Address Line 2 Foreign RRE Address Line 3 Foreign RRE Address Line 4 Optional Second, Third and Fourth line of mailing address of a foreign employer Use only if RRE has no US address

Fields for Medicare Reporting ORM Indicator Required On-going responsibility for medical: assumed when medical treatment is authorized or approved, not necessarily paid Fill with Y if there is on-going responsibility for medical May be statutorily implied; No Fault, Workers' Compensation ORM value remains Y even when ORM Termination Date is provided Valid Values: Y= Yes N = No

Fields for Medicare Reporting ORM Termination Date Situational: required when ongoing responsibility for medical has ended Date ongoing responsibility for medicals ended. Only applies to records previously submitted with ORM Indicator = Y ORM Termination Date is not applicable if claimant retains the ability to submit/apply for payment for additional medicals related to the claim Future dates are accepted but not more than 6 months greater than the file submission date When an ORM termination date is submitted, the ORM indicator must remain as "Y" Fill with zeroes if ORM Indicator = "N" or if a date for the termination of ORM has not been established Format: CCYYMMDD (example: 20110526 as today’s date)

Fields for Medicare Reporting TPOC Date (1 – 5) Situational: required if there has been a settlement, judgment or award Date of associated Total Payment Obligation to the Claimant (TPOC) Date payment obligation was established The date the obligation is signed if there is a written agreement unless court approval is required If court approval is required it is the later of the date the obligation is signed or the date of court approval If there is no written agreement it is the date the payment is issued Fill with all zeroes if there is no TPOC to report Must be greater than the CMS Date of Incident Must be zero if TPOC Amount is zero If more than five TPOCs need to be reported for a single claim, then put the most recent TPOC Date in TPOC Date 5 Format: CCYYMMDD (example: 20110526 as today’s date)

Fields for Medicare Reporting TPOC Amount (1 – 5) Situational: required if there has been a settlement, judgment or award Dollar amount of associated Total Payment Obligation to the Claimant (TPOC) Specify dollars and cents with implied decimal. No formatting (no $ , . ) Fill with all zeroes if there is no TPOC to report Must be non-zero if a non-zero value is submitted in TPOC Date

Fields for Medicare Reporting Funding Delayed Beyond TPOC Start Date (1 – 5) Optional If funding for the TPOC Amount is delayed, provide actual or estimated date of funding Fill with zeroes if not applicable Format: CCYYMMDD (example: 20110526 as today’s date)

Fields for Medicare Reporting Injured Party Representative Indicator Situational: required if the Injured Party has a Representative Code indicating the type of representative information provided If the Injured Party has more than one representative, provide the Injured Party's attorney information if available Valid values: A = Attorney G = Guardian/Conservator P = Power of Attorney O = Other Space = None

Fields for Medicare Reporting Injured Party Representative Last Name Situational: either Representative Last Name and First Name - or - Representative Firm Name is required if Injured Party has a representative Surname of representative Embedded hyphens (dashes), apostrophes and spaces accepted

Fields for Medicare Reporting Injured Party Representative First Name Situational: either Representative Last Name and First Name - or - Representative Firm Name is required if Injured Party has a representative Given or first name of representative May only contain letters and spaces

Fields for Medicare Reporting Injured Party Representative Firm Name Situational: either Representative Last Name and First Name - or - Representative Firm Name is required if Injured Party has a representative Representative Firm Name Representative TIN Optional Representative's Federal Tax Identification Number (TIN). If representative is part of a firm, supply the firm's Employer Identification Number (EIN), otherwise supply the representative's Social Security Number (SSN) May contain only spaces or numbers If no Representative TIN is available, fill with spaces or all zeroes

Fields for Medicare Reporting Representative Mailing Address Line 1 Situational: required if Injured Party has a representative First line of the mailing address for the representative. Street number and street name If no US address is available, fill with spaces and supply "FC" in the corresponding State Code Representative Mailing Address Line 2 Optional Second line of the mailing address of the representative Suite number, attention to, etc

Fields for Medicare Reporting Representative City Situational: required if Injured Party has a representative Mailing address city for the representative If no US address is available, fill with spaces and supply "FC" in the corresponding State Code

Fields for Medicare Reporting Representative State Situational: required if Injured Party has a representative. US Postal abbreviation State Code If no US address is available, fill with spaces and supply "FC" in the corresponding State Code.

Fields for Medicare Reporting Representative Mail Zip Code Situational: required if Injured Party has a representative 5-digit Zip Code If no US address is available, fill with spaces and supply "FC" in the corresponding State Code Representative Mail Zip+4 Optional 4-digit Zip+4 Code for the representative named above If not applicable or unknown, fill with zeroes (0000)

Fields for Medicare Reporting Representative Phone Situational: required if Injured Party has a representative Format with 3-digit area code followed by 7-digit phone number with no dashes or other punctuation If no US phone number is available, fill with spaces and supply "FC" in the corresponding State Code Representative Phone Extension Optional Telephone extension number of representative Fill with all spaces if unknown or not applicable

Fields for Medicare Reporting Claimant Relationship (1 - 4) Situational: required if Injured Party is deceased and Claimant is not the Injured Party Relationship of the claimant to the Injured Party/Medicare beneficiary. This field also indicates whether the claimant name refers to an individual or an entity/organization Valid values: E = Estate, Individual Name Provided F = Family Member, Individual Name Provided O = Other, Individual Name Provided X = Estate, Entity Name Provided (e.g. "The Estate of John Doe") Y = Family, Entity Name Provided (e.g. "The Family of John Doe") Z = Other, Entity Name Provided (e.g. "The Trust of John Doe") Space = Not applicable (rest of the section will be ignored)

Fields for Medicare Reporting Claimant TIN (1 – 4) Situational: required if Injured Party is deceased and claimant is not the Injured Party Federal Tax Identification Number (TIN), Employer Identification Number (EIN) or Social Security Number (SSN) of the Claimant May contain only spaces or numbers Must not match other claimant or claimants listed on the Customer Claim Input Record

Fields for Medicare Reporting Claimant Last Name (1 – 4) Situational: required if the Injured Party is deceased and the Claimant is not the Injured and Claimant Relationship is E (Estate, Individual Name), F (Family Member, Individual) or O (Other, Individual Name) Surname of Claimant Embedded hyphens (dashes), apostrophes and spaces accepted

Fields for Medicare Reporting Claimant First Name (1 – 4) Situational: required if the Injured Party is deceased and the Claimant is not the Injured and Claimant Relationship is E (Estate, Individual Name), F (Family Member, Individual) or O (Other, Individual Name) Given/First name of Claimant May only contain letters and spaces Claimant Middle Initial (1 – 4) Optional First letter of Claimant’s middle name Use only if Claimant Relationship is 'E', 'F' or 'O'

Fields for Medicare Reporting Claimant Entity / Organization Name (1 – 4) Situational: required if the Injured Party is deceased and the Claimant is not the Injured and Claimant Relationship is X (Estate, Entity Name), Y (Family, Entity Name), Z (Other, Entity Name) Name of the Claimant entity or organization

Fields for Medicare Reporting Claimant Mailing Address Line 1 (1 - 4) Situational: required if Injured Party is deceased and claimant is not the Injured Party (Claimant Relationship is not blank) Street number and street name If no US address is available, fill with spaces and supply 'FC' in the corresponding State Code Claimant Mailing Address Line 2 (1 – 4) Optional Second line of the mailing address of the claimant Suite number, attention to, etc

Fields for Medicare Reporting Claimant City (1 - 4) Situational: required if Injured Party is deceased and claimant is not the Injured Party (Claimant Relationship is not blank) Mailing address city for the claimant If no US address is available, fill with spaces and supply 'FC' in the corresponding State Code Claimant State (1 - 4) US Postal abbreviation State Code for the claimant If no US address is available, supply ‘FC’

Fields for Medicare Reporting Claimant Zip (1 - 4) Situational: required if Injured Party is deceased and claimant is not the Injured Party (Claimant Relationship is not blank) 5-digit Zip Code for the claimant If no US address is available, fill with spaces and supply 'FC' in the corresponding State Code Claimant Zip+4 (1 – 4) Optional 4-digit Zip+4 Code for the Claimant If not applicable or unknown, fill with zeroes

Fields for Medicare Reporting Claimant Phone (1 - 4) Situational: required if Injured Party is deceased and claimant is not the Injured Party (Claimant Relationship is not blank) Telephone number of the claimant Format with 3-digit area code followed by 7-digit phone number with no dashes or other punctuation If no US address is available, fill with zeroes and supply 'FC' in the corresponding State Code Claimant Phone Extension (1 – 4) Optional Telephone extension number of the claimant Fill with all spaces if unknown or not applicable

Fields for Medicare Reporting Claimant Representative Indicator (1- 4) Situational: required if Claimant has a representative. Code indicating the type of Attorney/Other Representative information provided for Claimant. If Claimant has more than one representative, provide information for his/her attorney if available. Valid values: A = Attorney G = Guardian/Conservator P = Power of Attorney O = Other Space = Not applicable (rest of the section will be ignored)

Fields for Medicare Reporting Claimant Representative Last Name (1 – 4) Situational: either Claimant Representative Last Name and First Name – or – Claimant Representative Firm Name is required if Claimant has a representative Surname of Claimant Representative Embedded hyphens (dashes), apostrophes and spaces accepted

Fields for Medicare Reporting Claimant Representative First Name (1 – 4) Situational: either Claimant Representative Last Name and First Name – or – Claimant Representative Firm Name is required if Claimant has a representative Given/First name of Claimant Representative May only contain letters and spaces

Fields for Medicare Reporting Claimant Representative Firm Name (1 – 4) Situational: either Claimant Representative Last Name and First Name – or – Claimant Representative Firm Name is required if Claimant has a representative Claimant Representatives firm name Claimant Representative TIN (1 – 4) Optional Claimant Representative's Federal Tax Identification Number (TIN) If representative is part of a firm, supply the firm's Employer Identification Number (EIN), otherwise supply the representative's Social Security Number (SSN) May contain only spaces or numbers If no Claimant Representative TIN is available, fill with spaces or all zeroes

Fields for Medicare Reporting Claimant Representative Mailing Address Line 1 (1 - 4) Situational: required if Claimant has a representative Street number and street name If no US address is available, fill with spaces and supply 'FC' in the corresponding State Code Claimant Representative Mailing Address Line 2 (1 – 4) Optional Second line of the mailing address of the Claimant Representative Suite number, attention to, etc

Fields for Medicare Reporting Claimant Representative City (1 - 4) Situational: required if Claimant has a representative. Mailing address city for the Claimant Representative. If no US address is available, fill with spaces and supply 'FC' in the corresponding State Code Claimant Representative State (1 - 4) Situational: required if Claimant has a representative US Postal abbreviation State Code for the Claimant Representative If no US address is available, supply 'FC‘

Fields for Medicare Reporting Claimant Representative Zip (1 - 4) Situational: required if Claimant has a representative 5-digit Zip Code for the Claimant Representative If no US address is available, fill with spaces and supply 'FC' in the corresponding State Code Claimant Representative Zip+4 (1 – 4) Optional 4-digit Zip+4 Code for the Claimant If not applicable or unknown, fill with zeroes

Fields for Medicare Reporting Claimant Representative Phone (1 - 4) Situational: required if Claimant has a representative Telephone number of the Claimant Representative Format with 3-digit area code followed by 7-digit phone number with no dashes or other punctuation If no US address is available, fill with zeroes and supply 'FC' in the corresponding State Code Claimant Representative Phone Extension (1 – 4) Optional Telephone extension number of the Claimant Representative Fill with all spaces if unknown or not applicable

Fields for Medicare Reporting Input Action Type Optional Indicator to explicitly delete claim record by sending CMS 'Action Type' value 1 (Delete) Valid Values: 0 or (Space) = Default; G&L sets appropriate CMS Action Type for this record (Add, Update/Change, Update for additional separate TPOC Report) 1 = Delete 2 = Stop Processing 3 = Eligibility Override

Fields for Medicare Reporting G&L Action Type Required Indicates whether Customer Claim Input records merge with or replace existing claim records Replace will be used when submitting fully-populated claim records; Claim File Input data replaces all existing claim data values, including default values such as spaces and zeros Merge preserves existing claim data values not explicitly provided in the Customer Claim Input file and is intended for GL Service (web portal) users Valid Values: M = Merge R = Replace

Fields Required for MSP Compliance Services Claim Status Required Utilized by Gould & Lamb to determine the proper MSP Compliance process to follow on the claim Valid Values: S = Settled P = Positioned for settlement. Active negotiations, settlement is immanent O = Open Policy limits have not been exceeded, Statute of limitations has not tolled Future claim payments possible C = Closed Policy limits have been exceeded, Statute of Limitations has tolled Future claim payments not possible

Fields Required for MSP Compliance Services Total Proposed Settlement Amount Situational. Required if Claim Status = P Utilized by Gould & Lamb to determine the proper MSP Compliance process to follow on the claim Dollar amount the claim handler the claim handler has evaluated for settlement and/or believes the claim will be concluded Specify dollars and cents with implied decimals No Formatting (no $ , .)

Fields Required for MSP Compliance Services Closing Future Medicals Situational. Required if Claim Status = P Identifies whether a settlement, judgment or award limits or forecloses future medical payment Utilized by Gould & Lamb to determine the proper MSP Compliance process to follow on the claim. May require the RRE to demonstrate ‘adequate consideration’ of Medicare’s interests Valid Values: Y= Yes N = No

Fields Required for MSP Compliance Services Plan Contact Department Name Situational: Required if the Injured Party is Medicare Eligible Name of department for the Plan Contact to which claim-related communication and correspondence should be sent Used for informal communications, not for recovery demand notifications

Fields Required for MSP Compliance Services Plan Contact Last Name Situational: Required if the Injured Party is Medicare Eligible Surname of individual that should be contacted at the Plan for claim-related communication and correspondence Embedded hyphens (dashes), apostrophes and spaces accepted Plan Contact First Name Given or first name of individual that should be contacted at the Plan for claim-related communication and correspondence May only contain letters and spaces

Fields Required for MSP Compliance Services Plan Contact Phone Situational: Required if the Injured Party is Medicare Eligible Telephone number of individual that should be contacted at the Plan for claim-related communication and correspondence Format with 3-digit area code followed by 7-digit phone number with no dashes or other punctuation Fill with zeroes if not available Plan Contact Phone Extension Optional Telephone extension number of individual that should be contacted at the Plan for claim-related communication Fill with all spaces if unknown or not applicable

Fields Required for MSP Compliance Services Plan Contact E-mail Address Situational: Required if the Injured Party is Medicare Eligible E-mail address for adjuster or point of contact for MSP compliance communication

Fields Required for MSP Compliance Services Employer Name Situational: Required if the Injured Party is Medicare Eligible and the Plan Type = ‘E’ (Workers’ Compensation) Information is needed by the Medicare Secondary Payer Recovery Center (MSPRC) when Gould & Lamb inquires as to Conditional Payments status.

Fields Required for MSP Compliance Services CPR Indicator Required. Indicates Conditional Payment Research is not required due to Medical Only status of claim or that Medical does not close as per State of Venue. Valid Value: 1 = No CPR (NCPR) Default = {space} if fixed width, null if tab delimited text

Product Liability Fields Product Liability Indicator Product Generic Name Product Brand Name Product Manufacturer Product Alleged Harm No longer in use

Appendix – Required Fields RRE ID ICN SSN Injured Party Last Name Injured Party First Name Injured Party Gender Injured Party Date of Birth CMS Date of Incident State of Venue ICD-9 ‘E Code’ ICD-9 Diag. Code 1 Plan Insurance Type

Appendix – Required Fields TIN TIN/Office Code Mailing Name TIN/Office Code Mailing Address 1 TIN Office Code City TIN Office Code State TIN Office Code Zip

Appendix – Required Fields Claim Number Policy Number ORM Indicator Claim Status G&L Action Type Plan Contact Phone Plan Contact E-Mail

Thank You John Miano Scott Huber Manager of Reporting Services john.miano@gouldandlamb.com Scott Huber Vice Pres. of Information Services scott.huber@gouldandlamb.com Telephone Dedicated Line: 00.1.941.567.1038 Toll Free Number: 866.672.3453 x1133 Dedicated Support E-Mail: Lloyds-MIR@gouldandlamb.com