Frequently, my colleagues and I are asked to define what the Centers for Medicare and Medicaid Services (CMS) consider ‘late reporting’ under the Medicare Medicaid State Children’s Health Insurance Program Extension Act (MMSEA) Section 111. Neither CMS or the Coordination of Benefits Contractor (COBC) has specified when, how or by whom the late filing penalties specified by Section 111 will be applied.
However, in reviewing the question, it becomes evident that the following terms, often used interchangeably, become confused: compliance, timeliness and late reporting.
The February 24, 2010 CMS Alert defines compliance as “punctual submission of quarterly claim input files which after the initial reporting cycle, are of sufficient quality which consistently follows CMS data submission protocols producing data that can be adequately processed and used.” In other words, the RRE must submit Claim Input files on their assigned quarterly submission date in a format acceptable to the Secretary for more than one consecutive quarter.
Timeliness of reporting is specified in the Non-Group Health Plan (NGHP) User Guide version 3.3 in Section 11.10.2. Total Payment Obligation to the Claimant (TPOC) settlements, judgments, awards or other payments are reportable when the injured party to (or on whose behalf) payment will be made has been identified and the TPOC amount for that individual has been identified. Should these criteria not be met as of the TPOC date, documentation should be retained evidencing when they had been met and the corresponding date reported in the ‘Funding Delayed Beyond the TPOC Start Date’ field which is contained within a record submitted in a Claim Input file during the RRE’s assigned quarterly submission period.
If an RRE has accepted ongoing responsibility for medicals (ORM) on a claim two events must be reported. The first is the assumption of ORM and the second is the corresponding end date reflected in the ORM Termination Date.
Section 12.4 of the NGHP User Guide advises that a claim record submitted to, and accepted by CMS as an ‘Add’ record may be indicated as “late” in the Claim Response via a ‘Compliance Flag’ code. Unlike error codes which indicate rejection, Compliance Flags mean that the record had been processed but non-compliant with Section 111 reporting requirements.
A Compliance Flag 01 indicates that the most recent TPOC Date on an ‘Add’ record received in a quarterly claim file submission is late if the TPOC Date is more than 135 days older than the start date of that same file submission period.
A Compliance Flag 03 indicates that the accepted ‘Add’ record received in a quarterly claim file submission is late if the ORM Termination Date is more than 135 days older than the start date of that same file submission period.
It’s important to note that Compliance Flag codes are only applied to records with an ‘Add’ Action Type which receive a 01 (accepted with ORM) or 02 (accepted no ORM) Disposition code in the Claim Response and do not apply to accepted ‘Update’ or ‘Delete’ Action Type records.
Therefore, “compliance” refers to the RRE’s overall conformity to Section 111 filing requirements, “timeliness” refers specified timeframes regarding reporting of ‘Add’ records and Compliance Flags act as notifications to the RRE of non-compliant (late) records which are tracked by COBC.
The May 1, 2012 CMS Alert ‘Restrictions on Additional File Submissions Lifted’, now removes the ‘Multiple files submitted’ Threshold Error. Previously, this Threshold error suspended the processing of additional Claim Inputs, if more than one were submitted during the RRE’s assigned submission period. Although intended to expedite electronic reporting of ORM Termination Dates, lifting of this threshold is not restricted solely to this purpose.
Allowance of multiple claim file submissions without restriction as to transaction type will inevitably lead to further confusion and may likely result in reassessment by CMS regarding specification and application of late reporting penalties.
Gould and Lamb is the global leader in MSP compliance offering first in class mandatory insurer reporting services. For questions or more information, please contact: Reporting Services Department at: 866.672.3453 x1122 or firstname.lastname@example.org.
(NGHP) User Guide Version 3.3
About the Author: John Miano is the Manager of Reporting Services for Gould & Lamb, LLC. His primary responsibility is directing the implementation of CMS Section 111 reporting programs for our clients. He has over 20 years experience in the Property and Casualty Insurance Industry and is currently an active committee member of the International Association of Industrial Accident Board Committees (IAIABC). He is also a former Executive Board Member of the Association of Workers Compensation Claim Professionals (WCCP) and is a Board Certified Workers Compensation claim adjuster (CWC).
Gould & Lamb is a global leader of MSA/MSP Compliance Services in the country, serving domestic and international insurance companies, third-party administrators and self-insured entities.