Medicare S econdary Secondary P ayer Payer Section 111

Transcription

1 1 Medicare Secondary Payer Section 111

2 The Medicare Secondary Payer legislation, section 111, requires insurers and self insurers to report all claims involving Medicareeligible claimants to CMS (Center for Medicare and Medicaid Services). Lines of business include Workers Comp, Liability and No-Fault claims, considered Non-Group Health Plans (NGHP). Quarterly reporting involves all Medicare-eligible claimants Recurring payments (WC and no-fault): report at first payment or acceptance of coverage and at end of ongoing payment responsibility (ORM) Single payment liability claims: report at Total Payment Obligation to the Claimant (TPOC) date. 2

3 Registration Companies must register all companies/ entities that will report to CMS, including this information: Tax Identification Number for each reporting entity The quarterly reporting period (assigned by CMS) Report direct or through a reporting Agency Authorized Representative Technical Contact Acknowledgement/Rejection CMS will acknowledge receipt of each file (quarterly) Each claimant/coverage will be acknowledged Claimants/coverages missing key fields will be rejected for correction. Corrections must be resubmitted in the next quarter 3

4 CMS Timelines Medicare Secondary Payer User Guide version 1.0 released March 16, 2009 Reporting required for all ORM claims open as of January 1, 2009 Reporting required for all TPOC claims open as of January 1, 2010 Open liability injury claims Claims with on-going medical responsibility (WC, some no fault) Sept. 30, 2009: registration deadline January 1 December 31, 2010: Company testing with CMS January 1 March 31, 2011: individual company live dates 4

5 ISO involvement Worked with CMS and industry trade groups (AIA, PCI and NAMIC) on legislation and response during comment period Met with CMS to assist industry in clarification of data elements and formats Conferred with numerous insurers on reporting requirements and the plan to utilize ISO as a reporting agency Developed gap analysis of CMS reporting fields vs. existing fields in Universal Format Developed draft of new UF with CMS records included Developed the ISO CMS Reporting Service 5

6 ISO Medicare Secondary Payer Reporting Service offers: a solution that is integrated with ISO ClaimSearch timely quarterly reporting to CMS assist in identifying Medicare-eligible individuals through a monthly query function timely warnings when claims with Medicare-eligible claimants are missing CMS-required fields a process for notifying customers of acknowledgements and claims rejected by CMS a process for correcting CMS rejections 6

7 ISO Secondary Payer Reporting Service 7

8 Determining Medicare Eligibility ISO offers an optional query of the CMS database on a monthly basis Uses the CMS-provided HEW software A query file for each RRE will be sent to CMS each month ISO queries the company s inventory of claimants that qualify for CMS reporting, who have not been identified as Medicare eligible Claimant s Ca a tsname, e,ss SSN, Date ateof Birth,,and Gender must be provided 8

9 Determining Medicare Eligibility (cont.) ISO will post the results in the Account Management section of ISO ClaimSearch Companies are responsible for updating claimants with the Medicare-eligibleeligible indicator to indicate claims to be sent to CMS 9

10 ISO Query Service to Determine Medicare Eligibility Company sends all claims to ISO ClaimSearch Company updates claims to determine which claims should be sent to CMS Company Claim System CMS Software ISO queries company s entire history of claims that qualify for CMS reporting with the CMS Software ISO posts the results to the Account Management section of ISO ClaimSearch Company Claim System 10

11 ISO Estimated Deliverables Updated Universal Format Manual April, 2009 Company Registration with CMS starts May, 2009 Testing on new CMS fields with ISO Early July, 2009 Reporting new CMS fields to ISO Mid July, 2009 Query file available for testing to July, 2009 determine Medicare eligibility Query File available in Production August, 2009 Assist companies with CMS testing Jan. 1 - Dec. 31, 2010 Companies start production reporting Jan. 1 - March 31,

12 Append DS SM Service An optional service that helps companies having trouble obtaining the SSN for claimant. When a claim is filed, the service: retrieves public-records information on the claimant SSN, Phone Number, Age, Date of Birth, Up to four previous addresses 1

13 Append DS SM Service Append DS also Searches the ISO ClaimSearch database for any matching claims using the SSN Appends the SSN and other new information retrieved to the ISO ClaimSearch Match Report 13

14 Participation in the ISO ClaimSearch Medicare Secondary Payer Reporting Service: To sign up, fill out the Compliance Reporting Form that you received in your for this Webinar. For more information or If you need a form, please claimsearchmsp@iso.com. com 14