GFRG Client Advisory Update 4/9/09: RRE Reporting of Multiple TPOC Amounts

To download a pdf of this advisory, click here.

On April 7, 2009, CMS published an alert (the “Alert”) related to the Medicare, Medicaid, and SCHIP Extension Act of 2007 (“MMSEA”). This alert provides guidance as to how an entity deemed to be a Responsible Reporting Entity (“RRE”) under the MMSEA will report multiple Total Payment Obligation to the Claimant (“TPOC”) amounts on the Claim Input File for Section 111 Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers’ Compensation reporting.

Version 1.0 of the Non-Group Health Plan User Guide (the “User Guide”) defines three values for the Action Type (Field 3) on the Claim Input File Detail record:

0 = Add
1 = Delete
2 = Update/Change
3 = Update for additional, separate TPOC Report

Due to input from RREs, Value 3 listed above has been removed. RREs indicated to CMS officials that a frequent situation may arise whereby an Add file is submitted indicating a TPOC Amount and Date and, subsequently, an Update file is submitted to report a different, additional TPOC Amount and Date for the same claim, reflecting a settlement for lost wages. Version 1.0 of the User Guide did not provide flexibility to the RRE to subsequently update one of those specific TPOC Amounts and/or Dates.

Instead, CMS has modified the reporting requirements for multiple settlement amounts. CMS has removed Value 3, and has added four additional TPOC Amount and corresponding TPOC Date fields at the end of the Claim Input File Auxiliary Record layout. CMS has also added a corresponding Funding Delayed Beyond TPOC Start Date field. These new fields only need to be submitted if the RRE has more than one, distinct, additional TPOC to report for a claim. The changes will be reflected in the next version of the User Guide.

These TPOC reporting changes may affect your practice. These changes allow more flexibility to the RRE when reporting multiple TPOC Amounts and/or Dates. However, incorrectly reported TPOC Amounts and/or Dates may confound settlements, effectively increasing your workload without producing additional revenue for your efforts.

With the publication of the Alert, CMS continues to amend previously reporting Section 111 compliance guidelines. Some issues, such as multiple TPOC amount reporting, are changing while other issues, such as applicability of Section 111 reporting to mass tort settlements, have yet to be settled. The industry is moving rapidly toward Section 111 reporting. We will continue to stay on top of the latest MMSEA news and let you know how your practice may be affected.

To read the alert, click here.