Medicare Secondary Payer Section 111 Reporting – Top 10 Issues for Companies and Agents

1. Medicare Secondary Payer Section 111 Reporting – Top 10 Issues for Companies and Agents

2. Medicare Secondary Payer – Section 111 Issues in Medicare Secondary Payer Reporting John Giknis, CPCU, SCLA, RPA, AIC Assistant Vice President ISO ClaimSearch Operations

3. Medicare Secondary Payer – Section 111Requirements • The Medicare Secondary Payer legislation, section 111, requires insurers and self insurers (Responsible Reporting Entities) to report all claims involving Medicare- eligible claimants to the Center for Medicare and Medicaid Services (CMS). Companies must register as an RRE with CMS prior to reporting. • Lines of business include Workers Comp, Liability and No-Fault claims, considered “Non-Group Health Plan” (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 only at settlement, judgment or award by Total Payment Obligation to the Claimant (TPOC) date

4. Medicare Secondary Payer – Section 111Issues • The RRE Determination • Who/What is the RRE? • Insurer • Self Insurer • Self-insured Pool • How many RRE’s are needed? • The CMS Registration Process • Group vs. Affiliates and Subsidiaries • TIN and Entity Name must be compatible • Selection of Agent – or direct reporting • Account Manager selection • “Invite” account designees

5. Medicare Secondary Payer – Section 111Issues • How to determine if the claimant is a Medicare recipient (beneficiary) • Claimant is 65 or over • Claimant is under 65, but qualifies for Medicare • Use the CMS Query • Complication from CMS Reporting Requirements • IT resources • Availability of data: SSN/DOB • Training staff on unfamiliar reporting elements • Obtaining information from archived files • Issues “under consideration” • Reporting periods • Thresholds

6. Medicare Secondary Payer – Section 111Issues • Determining Reporting Types • Ongoing Responsibility for Medicals (ORM) • Total Payment Obligation to Claimant (TPOC) • Quarterly Reporting • Reporting period (per RRE) • Separate file for acknowledgments/ rejections • Return results to company claims systems • Query Process • Same RRE issues • One file per RRE per month • Which claims (claimants ) to query • When to stop querying • Required fields: how to identify in history files

7. Medicare Secondary Payer – Section 111Issues • Rejections • Rejection file per RRE • How to identify prior to submission to CMS • How to correct and return – timing • CMS Communications/Direction • Changes in requirements, thresholds and timing • Issues “taken under advisement” • Indemnification Issues

8. Medicare Secondary Payer – Section 111 • Additional information on the ISO ClaimSearch Medicare Secondary Payer, Section 111 service • For more information or requests, please e-mail claimsearchmsp@iso.com • Overview and training documents available on the ISO CMS website: www.iso.com/msp