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Please find enclosed a follow up to our email of May 20, 2009, which announced the extension of the MMSEA deadlines.
Please find enclosed the following:
· Acronym Dictionary Page 2
· Frequently Asked Questions Page 3
· Registration Manual Page 8
· Registration Screen Shots Page 13
The Frequently Asked Questions and Acronym Dictionary will prove helpful if you are unclear about what MMSEA means for your organization.
It is vital that you read the Registration Manual and follow the recommended steps to ensure that your claims can be reported as required by the law.
If you have additional questions, please contact:
John Tobey
Vice President – Home Office Claims & Quality Assurance
REM
609.495.0059
john.tobey@remltd.com
-Or-
Duke Wolpert
Strategic Services Director
Gould & Lamb
866.672.3453 ext 1067
duke.wolpert@gouldandlamb.com
Acronym Definitions
AD: Account Designee, assigned by the Account Manager
AM: Account Manager, assigned by the Authorized Representative
AR: Account Representative, can contractually bind the insurer
COBC: Coordination of Benefits Center, responsible for receiving MQF and MIR files
COBSW: Coordination of Benefits Secure Web-Site, for RRE registration processing
CP: Conditional Payment
CPR: Conditional Payment Research
CMS: Centers for Medicare & Medicaid Services
CSA: Claim Settlement Allocation
EDI: Electronic Data Interface
LC: Lead Contractor, see MSPRC
MIR: Mandatory Insurer Reporting
MMSEA: Medicare & Medicaid State Children’s Health Insurance Program Extension Act
MP: MP: Medical Payment
MQF: Medicare Query Function, used to determine Medicare eligibility and reporting requirements
MSA: Medicare Set Aside allocation
MSP: Medicare Secondary Payer
MSPRC: Medicare Secondary Payer Recovery Contractor, responsible for recovery of CP
NAIC: National Association of Insurance Commissioners
ORM: Ongoing Responsibility for Medical
NGHP: Non-Group Health Plans, workers compensation, liability, auto NF
PIN: Personal Identification Number
PIP: Personal Injury Protection
RRE: Responsible Reporting Entity
RRE ID: Responsible Reporting Entity Identification Number
SCHIP: State Children’s Health Insurance Program
SFTP: Secure File Transfer Protocol
SFR: Self-Funded Retention
SIR: Self-Insured Retention
TIN: Tax Identification Number
TPA: Third Party Administrator
TPOC: Total Payment Obligation to Claimant
Frequently Asked Questions
What Is Medicare?
Medicare is a Federal program that pays for certain covered health care provided to enrolled individuals age 65 and older, certain disabled individuals, and individuals with permanent kidney failure. CMS – the Centers for Medicare & Medicaid Services – is the agency of the Federal government responsible for the oversight of the Medicare program, including implementation of the new Mandatory Insurer Reporting (MIR) requirements discussed below.
What is Medicare’s relationship to casualty insurance and self-insurance programs?
Medicare has been a “secondary payer” to workers compensation since the passage of the Medicare law in 1965, and has been a secondary payer to liability, no-fault and other forms of insurance, including self-insurance, since the passage of the Medicare Secondary Payer (MSP) statute in 1980.
In late December 2007, Congress passed a new amendment to the MSP known as Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007( MMSEA). This law requires all primary payers “to report to the Secretary of the Department of Health and Human Services all information the Secretary specifies is necessary to ensure proper coordination of benefits with the Medicare program.” Effective July 1, 2009, all liability insurers, no-fault insurers, workers compensation insurers and self-insurers will be required to identify and report to the Secretary all Medicare beneficiaries who have received a settlement, judgment, award, or other payment.
For reporting purposes, a “Medicare beneficiary” includes anyone who is a current beneficiary or was a beneficiary at any time prior to the event that triggers the reporting requirement.
What are the new requirements under Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007?
The 2007 amendments to the MSP provisions require certain enterprises, referred to as “Responsible Reporting Entities” or “RREs” to report specified information regarding "non-Group Health Provider (non-GHP)" arrangements (liability insurance, no-fault insurance, and workers compensation, including self-insurance) to CMS, January 1, 2010, retroactive to July 1, 2009. Data will be submitted electronically to CMS’ Coordination of Benefits Contractor (COBC). An RRE may report directly, or may assign an agent (usually a third party administrator (TPA)) to report on behalf of the RRE.
Do these requirements supersede prior Medicare requirements?
The new Mandatory Reporting requirements do not change or eliminate any existing MSP Act requirements. Medicare is still entitled to recover for any conditional payments that were otherwise payable under a “primary plan,” and Medicare is still entitled to require Medicare Set-Aside Allocations (MSA) for workers compensation settlements meeting certain requirements. REM has had a comprehensive workflow in place since Medicare began to require the use of MSAs in workers compensation claims.
Who is an RRE?
For all non-GHP plans, Congress has defined the term “applicable plan” to include all forms of liability insurance (including self-insurance), no fault insurance (including Personal Injury Protection (PIP) and medical payment (MP) provisions), and workers compensation laws or plans, whether insured or self-insured. This is an important term because the “Applicable Plan” is the Responsible Reporting Entity. Under the Medicare law an entity is “self insured” if it carries its own risk, whether by a failure to obtain insurance, or otherwise, and includes payments within a deductible when those payments are made to a beneficiary directly or through a third party.
Generally speaking, an entity is an RRE if that entity is primarily responsible for payments to a Medicare beneficiary.
The insurer will be the RRE under the following situations:
· The insurer makes qualifying payments to a Medicare beneficiary under a guaranteed cost
policy.
· The insurer makes qualifying payments to a Medicare beneficiary under a deductible or
retrospectively rated policy for which the insurer then seeks reimbursement from the insured
for amounts paid within the deductible.
· The insurer makes qualifying payments to a Medicare beneficiary under an excess or umbrella
program, rather than reimbursing the insured or underlying insurer for payments they made in
excess of their assumed layer of responsibility.
If you are a self-insured entity as defined by Medicare and you make payments directly (or through a third party administrator) to the beneficiary, then you are the RRE under the following situations:
· You have a true self-insured retention and make payments directly (or through a TPA) to a
beneficiary.
· You have a deductible or self-funded insurance program, and make payments directly (or
through a TPA) to a beneficiary. [Please note that if the insurer makes payments directly to a
beneficiary for amounts in excess of the deductible, they are the RRE for payments they
make; however, if you make payments in excess of the deductible or self-funded retention and
seek reimbursement from the insurer, then you are the RRE for the entire payment you make
to the beneficiary.]
· You have a self-insured plan with excess coverage – you will be the RRE for any payments
made directly (or through a TPA) to a beneficiary up to your self insured retention, and the
excess carrier will be the RRE for
Third-party administrators (TPA) are never RREs.
CMS has confirmed that TPAs of any type have no reporting responsibilities for liability insurance (including self-insurance), no-fault insurance or workers’ compensation.
Can an RRE assign MMSEA Reporting Requirements to their TPA or a vendor?
CMS will allow the use of agents for MMSEA Section 111 reporting. However, if an agent is
designated, the RRE remains responsible and accountable for compliance. Where an entity
reports on behalf of another entity required to report, it is doing so as an agent of the second
entity. Therefore, if a TPA will report on behalf of the insurance carrier, they would be
considered an agent. If that TPA who has been designated to report on behalf of an RRE would
like to use an agent, CMS will allow this and has set up their system accordingly. REM has designated Gould & Lamb as our preferred reporting agent. Gould & Lamb will serve as the reporting agent for all REM customers, unless REM is otherwise notified.
How will the RRE submit data to CMS?
The data submission process will take place electronically with the Coordination of Benefits
Contractor (COBC).
When do RREs need to register?
The registration Period is 5/1/09 – 9/30/09. RREs must register on their own behalf. Please see further registration instructions in the REM Customer Registration Manual.
How will the Registration Process work?
At registration an Authorized Representative (AR) will be assigned. This should be a person who can legally bind the RRE to the requirements of MMSEA Section 111 reporting. This person will not be a user on the COBC secure web site, but will sign the data use agreement as well as designate and sign off on the Account Manager (AM). At the time of registration, the AR will decide how many RRE ID numbers are needed (there is no limit to the number of RRE IDs which can be set up). The number of IDs needed will depend on how the RRE wants to set up the reporting process. If the RRE works with multiple TPAs and would like each individual TPA to be responsible for reporting they will register for an RRE ID for each TPA. If an RRE has 2 different claims systems (i.e. WC versus Liability) they should set up two RRE IDs so claims can be reported separately. If an RRE has several subsidiaries and wants to report those cases separately, they will register for multiple RRE IDs. Each RRE ID can send one data submission file per quarter and one query file per month. The Account Manager (AM) will manage the day to day processing of the data transfer. The AM can be an employee of the RRE, a representative of the TPA or a representative of an agent. Account Designees (AD) are people who will be designated by the AM and will have the ability to upload, monitor and transfer files. If an RRE wants to use their TPA to report, but the TPA wants to contract out to an agent to handle the reporting, CMS will allow this. The RRE will have an AR from their company designated. The TPA can be marked as the AM and the TPA will then name the agent (REM has designated Gould & Lamb) they would like to use for reporting purposes. The TPA can then designate people from the agent to be ADs.
Will CMS advise the RRE if a SSN is incorrect?
CMS indicated that the Query function will not identify if a SSN is incorrect. CMS has made the
decision that the only information that will be returned on the Query file is the claimant’s
Medicare status. Verification of Social Security status through the Social Security Administration
will still be required for MSP compliance purposes to determine the need for an MSA allocation
since CMS has no plans to offer any information other that Medicare entitlement status.
What are the penalties for non-compliance?
The statutory penalty that may be assessed against an RRE for non-compliance is $1,000 per claim per day of non-compliance. CMS has verbally stated that its initial intent is not to fine companies that are making a good-faith effort to comply with the law – its main objective is to obtain a “clean data feed.” CMS has indicated that it expects RREs to clean up bad data, and that it does intend to levy penalties for repeated submissions of “junk” data.
When will an RRE be required to submit live data to CMS?
Live Reporting will begin in the last quarter of 2009 from 10/1/09 – 12/31/09. However if
additional time is needed for testing, Refer to above. Each RRE will receive a designated
quarterly submission timeframe assigned by the COBC.
What if multiple RREs are involved in the same case?
Multiple RREs involved in the same settlement are all responsible for their own reporting under
each individual policy. This would apply when there is a workers’ compensation (WC) case
which involves a WC carrier as well as a third party liability carrier. This would also apply when
there is no-fault and liability coverage on a case. The reporting process is claimant specific as
well as policy specific.
Which claims need to be reported?
· All claims involving a Medicare beneficiary where a settlement, judgment, award or other
payment is made as of July 1, 2009 or later.
· All claims involving a Medicare beneficiary where ongoing responsibility for medical payments
exists as of July 1, 2009 regardless of the date of the initial acceptance of payment
responsibility. Note: Medicare is providing a limited extension on reporting these cases until 3rd
quarter submission timeframe in 2010 to allow time to go back and determine Medicare status.
What if a claimant is not a Medicare beneficiary at the time ongoing responsibility for
medicals (ORM) is assumed? Does that claim need to be reported?
If an individual is not a Medicare beneficiary at the time responsibility for ongoing medicals is
assumed, the RRE must monitor the status of that individual and report the case when the
individual becomes a Medicare beneficiary. This would be done by continuing to Query the
claimant on the RREs monthly Query file.
Exception: Responsibility for ongoing medicals has terminated before individual becomes a
Medicare beneficiary.
What about claims that are closed and inactive?
For ORM assumed prior to July 1, 2009, if the claim was actively closed or removed from
current claims records prior to January 1, 2009, the RRE is not required to identify and report
that ORM under the requirement for reporting ORM assumed prior to July 1, 2009. If such a
claim is later subject to reopening with further ORM, it must be reported with full information,
including the original DOI (as defined by CMS). What does this mean…? If a claim is closed/
inactive prior to 1/1/2009, the RRE does NOT need to report it unless a subsequent payment is
made causing the file to be reopen.
What about reporting thresholds?
CMS issued an alert dated 3/20/2009 :
http://www.cms.hhs.gov/MandatoryInsRep/Downloads/Allert_UserGuideSupp_NGHP.pdf
For workers’ compensation ORM, claims meeting the all of following criteria are excluded
from reporting for file submissions due through December 31, 2010:
a. “Medicals only."
b. “Lost time” of no more than 7 calendar days.
c. All payment(s) has/have been made directly to the medical provider.
d. Total payment does not exceed $600.00.
5
For liability insurance (including self-insurance) and workers’ compensation TPOCs, the
following dollar thresholds apply:
a. For TPOCs dates of July 1, 2009 through December 31, 2010, TPOC amounts of $0.00
-$5,000.00 are exempt from reporting except.
b. For TPOCs dates of January 1, 2011, through December 31, 2011, TPOC amounts of $0.00
$2,000.00 are exempt from reporting.
c. For TPOCs dates of January 1, 2012 through December 31, 2012, TPOC amounts of $0.00 -
$600.00 are exempt from reporting.
When and how will CMS fine for non-compliance?
CMS has continually stated on conference calls that they are more interested in good quality
data rather than passing out fines. CMS is expecting all RREs to register and test data
according to the current timeline in place. Real data is not required for testing, so the RRE
should register and begin testing as soon as possible. CMS has indicated in the past that the
first step in compliance with Section 111 is to follow the timeline. If RREs want to be in
compliance, they need to follow the register and test within the appointed timeframes and be
prepared to do live reporting in the last quarter of 2009. If the RRE is having any issues with
being ready to report, they need to discuss their issues with the assigned EDI Representative.
Does MMSEA Section 111 have an impact on or change the Medicare Set Aside Process?
No. CMS has made it clear that MMSEA Section 111 does not change or alter any legal
obligation/requirements under the Medicare Secondary payer statute (MSP). The MMSEA does
not have a direct impact on the MSP. Therefore, insurers are still responsible for protecting
Medicare’s interest still need to be considered for both past (conditional payments/liens) and
future (MSA) payments. MMSEA Section 111 does impose new claim reporting requirements on
claims handlers, which are in addition to the necessity of protecting Medicare as a secondary
payer under the MSP. The indirect impact is that CMS will now have a report outlining every
case where Medicare should be protected as a secondary payer. At any time in the future,
CMS can select cases to audit for MSP compliance.
How should a case involving deductibles or co-payments be reported?
CMS has stated that in the definition of “liability self-insurance,” deductibles and co-payments
constitute liability self-insurance, and require reporting by self-insured entities. However, in
order to avoid two entities reporting with possible confusion where the deductibles and/or co-payments are physically being paid by the insurer or its TPA, CMS is considering requiring such
deductibles and co-payments to be reported as part of the insurer or TPA’s report.
If there is a large deductible and the policyholder is going to pay up to the exhaustion of the
deductible that is considered a self-insured situation and should be reported by the policyholder.
When the deductible is exhausted the policyholder would report that coverage has ended. Then
the carrier, as an RRE, would need to report their coverage responsibility. Each RRE would
report their own respective coverage according to which entity is making the payments.
Where an entity is self-insured for a deductible but the payment of that deductible is done
through the insurer, then the insurer is responsible for including the deductible amount in the
amount it reports as a settlement, judgment, award or other payment.
Responsible Reporting Entity Registration Manual
for
REM Customers
Registration Flow Chart
Attention: Please read this document in its entirety.
REM has designated Gould & Lamb as the preferred Reporting Agent for our customers. Unless you have made other arrangements, Gould & Lamb will serve as your Reporting Agent.
If G&L is your Reporting Agent:
Please read this document in its entirety.
If G&L is not your Reporting Agent:
Gould & Lamb may be receiving data on your claims from one or more of your administrators but you may have chosen another Reporting Agent. If this is the case, you MUST complete the Gould & Lamb Registration Process to ensure your claims are processed successfully and relayed to your chosen Reporting Agent. Please read this document in its entirety.
If G&L is receiving your data from multiple sources:
Gould & Lamb may be receiving data on your claims from one or more of your administrators. Meaning if you have data coming to G&L from 3 different sources (ex. internal self-administered, TPA 1, and TPA 2), there will be 3 “Input Files”. If G&L is receiving multiple Input Files on your behalf, you must complete the Gould & Lamb Registration Procedure in Step 2 below for each Input File associated with an RRE ID. As an example, if you have 2 RRE IDs and the 1st RRE ID is handled by 2 different administrators and the 2nd RRE ID is handled by 3 different administrators, you would complete the registration 5 times. Each Input File has specific Gould & Lamb credential requirements. Please read this document in its entirety.
Overview:
The Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) was signed into law in December of 2007. The legislation impacts the handling of Workers' Compensation, Liability, Auto No-Fault, and Self-Insurers claims, defined by CMS as Non-Group Health Plans (NGHP). Effective July 1, 2009, NGHP insurers will be required to report substantial amounts of data to the Centers for Medicare & Medicaid Services (CMS) or suffer severe financial penalties.
Timeline:
· Registration for Non-Group Health Plans (NGHP) Mandatory Insurer Reporting (MIR) begins on 5/1/09 and continues through 09/30/2009.
· After registration insurers are required to test data feeds for MIR from 01/01/2010 through 03/31/2010, depending on assigned reporting dates from CMS.
· Initial live data feeds will begin on 04/01/2010.
This is a simplified document focused solely on the registration as a Responsible Reporting Entity (RRE) from the perspective of the Authorized Representative. You should already know if you are an RRE, how many RRE IDs your company needs and who your Reporting Agent is for each RRE ID obtained. Medicare has provided guidance on how to register in their most recent NGHP User Guide released on 3/16/09. A copy of the User Manual is available by clicking on the following link:
http://www.cms.hhs.gov/MandatoryInsRep/Downloads/NGHPUserGuide031609.pdf.
CMS Registration Overview:
Registration as an RRE is a simple process that requires the following:
Step 1: Go to www.Section111.cms.hhs.gov to register as an RRE and enter the required information on your company, subsidiaries, and Authorized Representative. To help determine who your Authorized Representative is, contact us at clientservices@gouldandlamb.com and request a copy of the RRE Overview.
Step 2: You will receive the CMS Registration Confirmation letter via United States Postal Service (USPS) and must send the letter to your Reporting Agent. Detailed instructions are provided in this document on who and where to send this information.
Note: Your Reporting Agent will complete the second step of CMS registration, which involves setting up your account for reporting and determining the file transmission method to CMS after receiving the CMS Registration Confirmation Letter. You must complete a separate Gould & Lamb Registration if we will be receiving ANY of your claims data in which you are the RRE even if Gould & Lamb is not your Reporting Agent. See the Gould & Lamb Registration Process Instructions below.
Step 3: After the completion of Step 2, you will receive the CMS Profile Report via email. You must sign and return this agreement to Coordination of Benefits Center (COBC). Data testing can not begin until this is completed. Failure to complete this in a timely manner may result in $1000/day/claim penalty.
As we have discussed in a previous Gould & Lamb document “RRE Overview”, register as early as possible in the timeline. The earliest you may begin registration is May 1st, 2009. Contact us at clientservices@gouldandlamb.com to request a copy of this document.
Detailed Registration Process Instructions
Step 1: CMS Registration by the Authorized Representative:
Click on the following link to begin CMS registration, www.Section111.cms.hhs.gov. When you go to the site be prepared to enter the following information:
· Company Name and EIN/TIN
· Company Address, including telephone and fax
· Reporting Type (either GHP or Liability/No-Fault/Workers’ Compensation)
· NAIC Number
· Subsidiary Company Names, NAIC Numbers, and EIN/TINs
· Authorized Representative Contact Information and Mailing Address
Step 2: Receipt of CMS Registration Letter
The CMS Registration Letter will be mailed to you via USPS. The letter contains your RRE ID and PIN to access your account through the Coordination of Benefits Secure Website (COBSW). A scanned copy of this letter MUST be provided to your Reporting Agent.
· Since Gould & Lamb has contracted with REM and will be receiving your claims data, you
must register with Gould & Lamb, even if Gould & Lamb is not your Reporting Agent
for these claims. Refer to the G&L Registration Process below.
· It is CRITICAL to link your administrators and RRE ID(s). If G&L is receiving multiple Input
Files on your behalf, you must complete the Gould & Lamb Registration steps below for each
Input File associated with an RRE ID using the proper credential provided by G&L for each
source/administrator Input File.
GOULD & LAMB REGISTRATION PROCESS:
To simplify the G&L Registration Process, Gould & Lamb has created a web-site to submit the CMS letter and required information to setup your account(s) to ensure a proper implementation.
· Go to http://onesource-reg.gouldandlamb.com
· Login with the following source credential:
o Customer ID: riskenterprise3
· If Gould & Lamb is your Reporting Agent, complete all of the fields and upload your scanned
CMS Letter.
· If Gould & Lamb is not your Reporting Agent, complete all of the fields and select “Other” in the
Reporting Agent section. Complete the contact information fields for your Reporting Agent.
Uploading your scanned CMS Letter is not required.
Step 3: Receiving the CMS Profile Report
After you register with G&L and upload the CMS Registration Letter to Gould & Lamb through the G&L web-site, we will complete the second step of the CMS registration process and CMS will send the Authorized Representative a CMS Profile Report via email. Simply review, sign, and return this Profile Report to the COBC via fax, email, or regular mail.
This concludes the registration process, congratulations!!!
Helpful Links:
CMS Dedicated Site for Mandatory Reporting:
http://www.section111.cms.hhs.gov
Registration Overview: http://www.cms.hhs.gov/MandatoryInsRep/Downloads/RegistrationOverview.pdf
Once these three steps have been completed, Gould & Lamb can begin sending data to CMS to test interface connectivity. Attached to this document are print screens of CMS registration site and the required information. Should you have any questions, please contact us via email at mir@gouldandlamb.com. Thank you for your time and cooperation.
COBSW Screenshots
Login Warning: click “I accept”
Welcome Page: click “New Registration”
Account Registration: click “continue”
RRE ID Profile Information: enter required company information
Corporate Structure: enter subsidiaries that will be reporting under this RRE ID
Authorized Representative Information: enter contact information
Registration Summary: confirm the information entered
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