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  • November 19, 2009
  • November 4, 2009
  • August 10, 2009
  • July 28, 2009
  • July 7, 2009
  • May 29, 2009

    The Centers for Medicare & Medicaid Services (CMS) announced on May 11, 2009 that it has extended the time frame for liability, no-fault, and workers' compensation insurers (non-GHPs) to comply with the reporting requirements mandated by Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Section 111). These insurers (or their designees) must register as Responsible Reporting Entities (RREs) with CMS and test their electronic reporting capabilities before submitting actual claims data. Pursuant to the new time frame, non-GHP insurers will now have until September 30, 2009 to register with CMS, and actual reporting need not begin until the second quarter of 2010 after claims testing in the first quarter. These new deadlines give non-GHPs an extra three months to come into compliance with the new mandatory Medicare reporting regime.

    In-depth explanations of the Section 111 reporting requirements for non-GHPs are available at www.wileyrein.com/docs/publications/14249.pdf and www.wileyrein.com/publication.cfm?publication_id=14331.

    The revised implementation timetable is comprised of the following 5 phases.

    Phase 1:  Development Period (Prior to Registration)
    RREs will develop a system for collecting the data CMS requires for each reportable claim.  CMS will supply the Internet connection and file layouts for RRE data transmission to the Coordination of Benefits Contractor (COBC). RREs (or their agents) can choose to submit data via the Coordination of Benefits Secure Website (COBSW) using Hypertext Transfer Protocol over Secure Socket Layer (HTTPS) or Secure File Transfer Protocol (SFTP) or, for large amounts of data, via Connect:Direct using the AT&T Global Network System (AGNS). CMS is providing free computer-based training.

    Phase 2:  Registration Period (May 1, 2009 - September 30, 2009)
    RREs will register online by logging on to a secure website with the COBC.  The RRE must complete the registration process directly; it may not do so through an agent.  Once the RRE submits its application via the secure website, CMS will begin working with the entity to set up the data reporting and response process. 

    Each RRE must register for and obtain an assigned RRE ID for every claim file it will submit each quarter. Because an RRE is permitted to submit a particular claim file only once per quarter, an RRE may need to register for multiple ID numbers.  For example, if an RRE operates two different claims systems, one that processes no-fault claims and another that processes workers' compensation claims, it may be difficult for the RRE to combine the reports of these systems in order to submit a single claim file to CMS.  Accordingly, the RRE could register for two RRE IDs, one ID for the no-fault claims system and one ID for the workers' compensation system, and submit two claim files each quarter.

    Phase 3:  Testing Period For Query Input Files (Begins July 1, 2009)
    The Query Function will be available as of July 1, 2009 for an RRE that has completed registration and is in testing status, which means that the COBC has received the RRE's signed Profile Report.  Both test and production Query Input Files will be accepted and processed for an RRE ID in testing status. Although RREs have until September 30, 2009 to register, RREs cannot submit Query Input Files until they have completed registration and are in testing status for the applicable RRE ID(s).  

    Phase 4:  Testing Period For Claim Input Files (January 1, 2010 - March 31, 2010)
    CMS also has moved the testing period for claim input files back a quarter although it appears that the agency may permit an RRE to begin testing in 2009 if it has successfully completed registration. Once testing is concluded for an RRE ID, the system will set the RRE ID to production status.  Additional test files will continue to be accepted and processed after production status has been attained up until actual reporting begins.

    RREs that complete testing during the first quarter of 2010 may submit their first live production file(s) during that quarter. RREs are not required to submit their first live production file(s) until the second quarter of 2010.

    Insurers may, but are not required, to use actual data to test their reporting systems.  Manufactured (or dummy) data can be used to determine whether or not the submission and response files work.  

    Phase 5:  Initial Production Claim Input File Submissions Due (April 1, 2010 - June 30, 2010)
    All RREs must begin their quarterly production reporting no later than the file submission time frame assigned to each RRE ID by CMS.

  • April 20, 2009

    CMS Clarifies Mandatory Medicare Reporting Requirements For Liability, No-Fault and Workers’ Compensation Insurers

    I.         Extension of Testing Period

    The Centers for Medicare & Medicaid Services (CMS) recently announced that it has extended the data transmission testing period for liability, no-fault and workers’ compensation insurers required to electronically report the resolution of claims involving injury to Medicare beneficiaries under Section 111 of the Medicare, Medicaid and SCHIP Extension Act (MMSEA).  These insurers (or their designees) must register as Responsible Reporting Entities (RREs) with CMS and test their electronic reporting capabilities before submitting actual claims data.  Although testing may still begin at an insurer’s election in July 2009, CMS has extended the testing period through December 31, 2009.  As a result, RREs are now required to complete testing and begin submitting live data files no later than their assigned submission window during the first three months of 2010, three months later than originally required.  

    II.       Dollar Thresholds

    In addition to giving insurers more time to test their electronic reporting processes, CMS has established two categories of reporting thresholds for some liability and workers’ compensation claims that will limit, on an interim basis, the number of claims insurers must report: one for “Ongoing Responsibility for Medicals” (ORM) and a second for “Total Payment Obligation to the Claimant” (TPOC). No thresholds previously existed. In contrast, there is no dollar threshold for ORM or TPOC claims for no-fault insurers. They must report all claims involving injury to Medicare beneficiaries regardless of value.

    The following new thresholds apply:

    Thresholds for Ongoing Responsibility for Medicals (ORM):  Workers’ Compensation Insurers, through December 31, 2010, may choose not to report claims that meet all of the following criteria:
    - "Medicals only"
    - "Lost time" of no more than 7 calendar days
    - All payment(s) made directly to the medical provider
    - Total payment does not exceed $600

    Liability Insurers have no de minimus dollar threshold under this category, which means they must report all claims accepting any responsibility for payment of covered medical services for Medicare beneficiaries.

    Thresholds for Total Payment Obligation to the Claimant (TPOC):  For both liability and workers’ compensation insurers, during the noted periods below within the specified dollar ranges, there are no TPOC reporting requirements:
     
    Interim PeriodTPOC
    AmountReporting Exemption July 1, 2009 – Dec. 31, 2010 $0 - $5,000 Full Jan. 1, 2011 – Dec. 31, 2011 $0 - $2,000 Full Jan. 1, 2012 – Dec. 31, 2012 $0 - $   600 Full

    It is important to note that where there are multiple TPOC claims reported by an RRE on one record, the combined TPOC must be considered in determining whether or not the TPOC amount has been exceeded.

    For TPOC claims involving a deductible, where the RRE is responsible for reporting both the deductible and any amount paid above the deductible, the threshold applies to the total of these two figures.