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

2. 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.

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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: as today’s date)

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

11. 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

12. 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: as today’s date)
Liability claims; post 5-Dec-1980
Workers' Compensation claims; post 1-Jan-1965

13. 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: as today’s date)

14. 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:

15. 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:

16. 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:

17. 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

18. 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

19. 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

20. 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)

21. 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

22. 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

23. 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

24. 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 : "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'.

25. 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)

26. 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: as today’s date)

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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: as today’s date)

36. 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: as today’s date)

37. 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

38. 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: as today’s date)

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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.

46. 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)

47. 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

48. 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)

49. 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

50. 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

51. 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'

52. 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

53. 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

54. 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’

55. 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

56. 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

57. 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)

58. 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

59. 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

60. 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

61. 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

62. 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‘

63. 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

64. 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

65. 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

66. 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

67. 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

68. 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 $ , .)

69. 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

70. 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

71. 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

72. 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

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

74. 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.

75. 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: = No CPR (NCPR) Default = {space} if fixed width, null if tab delimited text

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

77. 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

78. 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

79. Appendix – Required Fields
Claim Number
Policy Number
ORM Indicator
Claim Status
G&L Action Type
Plan Contact Phone
Plan Contact

80. Thank You John Miano Scott Huber Manager of Reporting Services
Scott Huber
Vice Pres. of Information Services
Telephone Dedicated Line:
Toll Free Number: x1133
Dedicated Support