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

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

Text Translations  <3  </3  ILY  6Y

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.

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.

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.

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

Who must report? RRE

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. AlertWhoMustReportrev pdf

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

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.

Text Translations  LMBO  ROTFLMBO

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.

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

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

Missing SSN or DOBs  At claim intake?  During the claim investigation.  Form recommended by CMS.  Documentation in the claims file. HHICNSSNNGHPForm.pdf

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….

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

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?

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?

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? HPUserGuideV3.1.pdf

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.

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

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.

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).

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.

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?

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

Thank you!

Jill Breard Director of RMS Operations LWCC (225)