CMS updates reporting requirements for auto no-fault claims to CMS
The Centers for Medicare and Medicaid Services (CMS) recently alerted stakeholders that they updated the requirements for reporting auto no-fault claims in the Non-group Health Plan (NGHP) Section 111 User Guide. This update affects responsible reporting entities (RRE) and associated third-party claims administrators (TPA) who insure or manage No-Fault auto claims and are required to report to CMS under the Medicare Secondary Payer (MSP) Mandatory Reporting Provisions Section 111 of the Medicare, Medicaid, and SCHIP Extension Act (MMSEA) of 2007.
Updated requirements from CMS:
- Responsible Reporting Entities (RREs) must combine both Med Pay and Personal Injury Protection (PIP) coverage limits for Section 111 reporting purposes. This applies to claims where separate Med Pay and PIP coverages are being paid out on claims for the same injured Medicare beneficiary/claimant and same incident under a single auto policy.
- Ongoing responsibility for medicals (ORM) cannot be terminated until both Med Pay and PIP coverage limits are exhausted.
- The dollar amount for the combined No-Fault policy limit must accurately reflect two decimal places. For example, a policy limit of $5,000 should be reported as $5,000.00.
What you should do:
- If claimant is Medicare entitled per Section 111 reporting, pay the provider or reimburse the claimant from Med Pay and/or PIP coverage parts and turn on the ORM indicator under a No-Fault claim type.
- When settling all aspects of the auto claim, consider using all No-Fault (Med Pay/PIP) funds first from the Med Pay and/or PIP coverage parts before using funds under the liability coverage part.
- When settling and releasing all responsibility for medical expenses, report an ORM termination date via Section 111 under the No-Fault claim type.
- When spending/exhausting all No-Fault (Med Pay/PIP) policy limits, submit the
No-Fault Case Closure form to CMS found at https://www.cms.gov/files/document/no-fault-case-closure-detail.pdf
- When settling and releasing all responsibility including medical expenses, report a settlement amount and date known as total payment obligation to the claimant (TPOC) under the liability claim type via Section 111 reporting.
We’re here to help
If you need assistance, contact your Medicare Secondary Payer partner at Optum Settlement Solutions.
For further information , contact Lavonya Chapman, Associate General Counsel of Optum Settlement Solutions at firstname.lastname@example.org.