MMSEA Section 111: What is Late Reporting?

John MianoFrequently, 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 mirservice.support@gouldandlamb.com.


NGHP Mandatory Insurer Reporting User Guide(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.

Implementation Timeline for Liability Claims – Which Threshold Applies?

John MianoOn September 30, 2011 CMS published its ‘Revised Implementation Timeline for Certain Liability Insurance Total Payment Obligation to the Claimant (TPOC) Settlements, Judgments, Awards or Other Payments.’ A graduated implementation timeline based on the TPOC Amount and TPOC Date was established. Importantly, this implementation delay is ‘optional’.

Preceding the September 30th Alert, the latest version of the NGHP User Guide, dated August 17, 2011, set out differing TPOC Dates and Amounts in Section 11.4.

To confuse matters more, MSPRC issued a Beneficiary Alert on September 6th establishing a $300 Threshold on Liability settlements advising that Medicare would not recover conditional payments from cases where the lump sum settlement is $300 or less (under certain conditions).

Which Implementation Timeline and Liability Reporting Thresholds should one apply to their claims? The answer lies with the Responsible Reporting Entity (RRE), as they are ultimately responsible for compliance.

  • First, the September 6th Alert is directed at Medicare Secondary Payer (MSP) provisions and not Mandatory Insurer Reporting (MIR). Although MSP and MIR provisions are related, they’re not the same.  The $300 threshold does not apply to MIR.
  • Second, an RRE must consider certain factors when determining whether to utilize the Optional delay afforded by the September 30th CMS Alert:
    • Does the RRE report multiple lines of business other than Liability? If so, CMS strongly recommends voluntary reporting and the User Guide timeline and thresholds should be applied.
    • What is the Claims Administrator’s ability to capture and submit necessary data? If the implementation timeline and reporting thresholds in the User Guide are adhered to, the optional delay in the September 30th Alert reduced the number of claims for reportable.  If the RRE and/or claim administrators have the ability to report using the implementation timeline, reporting should be undertaken.

One reason for utilizing the optional implementation timeline is that by reporting claims using the interim reporting thresholds in the August 17th User Guide, claim volumes reported will be higher due to the lower threshold.  It is assumed the RRE (identified as the primary payer) would be unnecessarily exposed to conditional payments (Medicare liens). Again, MIR and MSP provisions are related but not the same. Regardless of whether a Liability claim TPOC meets either reporting threshold, Medicare’s interest must be taken into consideration.

Claim operations should also be considered when deciding which implementation timeline and liability reporting thresholds should be used.  If the RRE’s and/or TPA’s claim staff is trained and ready to report, additional delays and multiple thresholds only increase the likelihood of human error and increase the potential for penalties.


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.

Medicare Reporting

Medicare Reporting; Revised Timeline for Liability Insurance

Medicare Reporting Revised TimeLineIn Nov 2010, CMS revised the Medicare reporting timeline for Liability claims where there had been a Total Payment Obligation to the Claimant (TPOC) with no involvement of ORM.

Early November of 2010, Centers for Medicare and Medicare Services (CMS) issued a Mandatory Insurer Reporting Alert Update advising as to a revised time line for the Medicare reporting of Liability claims where there had been a TPOC – settlement, judgment, award or other payment with no involvement of on-going responsibility for medical (ORM).

This Alert advised that TPOC’s with dates on or after 10/1/2011 would now require first submission to CMS per the Responsible Reporting Entities (RRE’s) assigned quarterly time period for the first calendar quarter of 2012 but also welcomed and encouraged TPOC reporting  with dates prior to 10/1/2011.

5 Benefits Why RREs Should Voluntarily Report Liability Claims Now

  1. Claims administrators handling multiple lines of business inclusive of No Fault and Workers’ Compensation won’t need to exclude Liability claims from data feeds required for Quarter 1 Medicare reporting.
  2. Claims administrators handling these Liability claims will not require re-training prior to required Medicare reporting Quarter 1 2012.
  3. Liability claim handlers may gain necessary experience in the comprehensive collection of required Mandatory Insurer Reporting data.
  4. Plaintiffs, Plaintiff Counsel and State venues may become acclimated to data requirements and affected time periods for settlement regarding claims involving Medicare Eligible Injured Parties.
  5. Medicare voluntary reporting will not carry penalty exposure for late or delayed reporting.

The greatest benefit of early Medicare reporting is invaluable in terms of observed, anticipated behavior of CMS edits. This experience will to improve data quality when Medicare reporting becomes required and minimize late reporting penalties.

Mandatory Insurer Reporting TPOC

3 TPOC Truths on CMS Mandatory Insurer Reporting

I shared a passionate article John Miano, our Manager of Reporting Services wrote recently about the upcoming CMS Mandatory Insurer Reporting due to take effect January 1, 2011. John understands the importance and inherent ramifications our clients will face if they are not properly prepared when Mandatory Insurer Reporting takes place. In this article, John offers astute insights and answers questions many of you have asked.Centers for Medicare Medicaid Services

Written by John Miano, Manager of Reporting Services, Gould and Lamb

As we approach the Mandatory Insurer Reporting mandate of January 1, 2011, serious questions remain as to issues such as the identity of the Responsible Reporting Entity (RRE) and who must report a Total Payment Obligation to the claimant or TPOC (settlement, judgment award or other payment).

By now, most in the industry know the basics; RRE’s are required to report claims where ongoing responsibility for medical benefits (ORM) exists as of January 1, 2010 and are subsequently required to report  TPOC amounts when the TPOC settlement date is October 1, 2010 or later.

In the latest version of their User Guide, CMS provides guidance:

Section 7.1 – Who Must Report, explicitly defines the differences between Deductible versus self insured retention (SIR) programs and identifies issues specific to Deductible versus Re-Insurance, Stop Loss, Excess and Umbrella Insurance programs. Sections 11.4 and 11.5 clearly specifies TPOC Interim Reporting Thresholds and reporting of multiple TPOC’s.

Questions amongst insurers, however, have deepened as to who must report and the TPOC amount each RRE must report.

CMS TPOC Definition Overrules Insurer Description

NGHP Mandatory Insurer Reporting User GuideIf it walks and quacks like a duck, it’s a duck regardless of how it is perceived by the industry. In determining who the RRE may be, keep it simple; CMS acknowledges that their definitions differ from those utilized by the industry. Instruments of insurance are often identified by different names dependent on company or jurisdiction.

Example – A program behaves similar to reinsurance but has other customer specific components. The most general definition and intent should be applied when referring to CMS definitions. guidelines for the applicable plan per the NGHP User Guide should be applied.

With One Exception, RRE’s MUST REPORT TPOC Amounts

Each RRE must report those TPOC amounts (assigned or proportionate share) for which they are responsible.

The only notable exception is in regard to Liability Claims in jurisdictions which specify joint and several liability. Each RRE must report the total amount of the TPOC and not the assigned or proportionate share.

When In Reporting Doubt: CMS Is King

The only expert regarding Mandatory Insurer Reporting (MIR) is CMS. Should you have unresolved questions affecting timely compliance, CMS is the only true expert to be utilized. Any other opinion from a third party or legal counsel is just that, an opinion or interpretation.

The best place to start is with the Coordination of Benefits Contractor (COBC) Electronic Data Interchange (EDI) Representative assigned to the RRE. If you are unsure as to the identity of the EDI Representative, contact the COBC EDI Department at 646-458-6740 and ask for assistance. Outlines in Section 18.2 of the CMS User Guide are contact protocols and escalation processes.

Gould and Lamb, LLC has successfully transmitted data via OneSource on over 1100 insurance claims. The query process has been in place since July, 2009 evidencing that G&L is prepared for the reporting process and to assist clients with their ongoing mandatory insurer reporting benefits (ORM) and TPOC obligations. While the User Guide is unclear in many respects, the above observations in conjunction with the guide itself will help to avoid confusion and ensure compliance.

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