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VISIONS FOR THE FUTURE. Translating CMS Terminology for your Claims Department And How to translate your children’s text messages. Medicare Secondary Payer Mandatory Reporting. Imposed through Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA). Text Translations. - PowerPoint PPT Presentation
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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 PayerMandatory 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.
http://www.cms.gov/MandatoryInsRep/Downloads/AlertWhoMustReportrev052610.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.
http://www.cms.gov/MandatoryInsRep/Downloads/NGHHICNSSNNGHPForm.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?
http://www.cms.gov/MandatoryInsRep/Downloads/NGHPUserGuideV3.1.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 CodingFor 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 CodingFor 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!
