Frequently Asked Questions (FAQ)
Medicare Secondary Payer Reporting Service
If you have chosen ISO ClaimSearch® as your agent for CMS Section 111 reporting, there are numerous resources and training tools available to your company.
* Please Note: The following information is available to participating customers who have an active User ID and password for ISO ClaimSearch. To access these resources please click on the User Manuals and Guides link on the ISO ClaimSearch home page. *
- ISO ClaimSearch Medicare Secondary Payer User Guide
- ISO ClaimSearch Medicare Secondary Payer Training Webinar Recording
- CMS ICD-9 and Cause of Injury Code Lists
- CMS Disposition and Compliance Codes
- ISO ClaimSearch Medicare Secondary Payer User Meeting
CMS Quick Tips
- Group Reporting Periods
|Days 1–7 of the first month of each quarter|
|Group 1||Days 1–7 of the first month of each quarter|
|Group 2||Days 8–14 of the first month of each quarter|
|Group 3||Days 15–21 of the first month of each quarter|
|Group 4||Days 22–28 of the first month of each quarter|
|Group 5||Days 1–7 of the second month of each quarter|
|Group 6||Days 8–14 of the second month of each quarter|
|Group 7||Days 15–21 of the second month of each quarter|
|Group 8||Days 22–28 of the second month of each quarter|
|Group 9||Days 1–7 of the third month of each quarter|
|Group 10||Days 8–14 of the third month of each quarter|
|Group 11||Days 15–21 of the third month of each quarter|
|Group 12||Days 22–28 of the third month of each quarter|
- Ongoing Responsibility for Medicals (ORM) Information:
- No-fault and Workers Compensation
- Includes all medical payments coverage
- Reporting required at first payment or acceptance of coverage and at termination of reporting responsibility
- Any open ORM claim as of 1/1/10
- Threshold for Workers Comp medical claims is $750
- Extended from 12/31/2011 to 12/31/2012
- Lost time – less than 7 days
- Payments direct to the medical provider
- ORM Termination date must be no more than 180 days from submission date.
- Note: requirement that ORM Termination date must be at least 30 days from date of loss has been rescinded effective 11/1/2010
- Total Payment Obligation to the Claimant (TPOC) Information:
- Liability and Bodily Injury
- LIABILITY TPOC claim reporting is now required effective 1/1/2012 on claims settled effective 10/1/2011
- TPOC's on non-liability claims continues at 10/1/10
- No-Fault and Workers Compensation TPOCs are subject to original dates
- LIABILITY and WC TPOC Threshold – Total Payments
- $5,000 * 1/1/2011 – 12/31/12
- $2,000 1/1/2013 – 12/31/13
- $600 1/1/2014 – 12/31/14
* For companies that report in 2011
ISO as Your Reporting Agent
If my company chooses ISO as our agent, will we need to send a separate file to ISO ClaimSearch® for CMS reporting?
No. Your company can submit claims to the Department of Health and Human Services Centers for Medicare & Medicaid Services (CMS) as part of the regular Universal Format Claims Reporting process. Participants must submit claims to ISO ClaimSearch in Universal Format to be in compliance with CMS Section 111 reporting.
If my company has more than one Responsible Reporting Entity (RRE), how do I ensure my claim will be submitted under the correct code?
When a company has more than 1 RRE, TIN or Site ID, the customer is responsible for entering this information on the claim. ISO cannot derive the RRE, TIN or Site ID when there is more than 1 listed under a company.
Will my claims previously submitted in Legacy format be sent to CMS?
ISO will query all open casualty claims, regardless of their Legacy or Universal Format status. However, once you have received the Query information you will not be able to update the required CMS fields on a Legacy claim. You must convert these files to Universal Format in order for ISO ClaimSearch to submit your claims to CMS.
If my company has a system-to-system interface with ISO ClaimSearch, will I be able to add the CMS required fields using the ISO ClaimSearch website?
Yes. If your company sends the initial claim using your system-to-system interface, and the claim does not contain all of the fields required for a CMS filing, you may update your claim using the ISO ClaimSearch website. Any fields added via the web will not be blanked out by a system replacement which does not contain values in those fields. The information you enter via the web can be changed by a system replacement, but will not be blanked out by a system replacement.
Determining Medicare Eligibility
Will ISO provide the Query offered by CMS to determine if a person is Medicare eligible?
Yes. If you chose to use ISO for the query process, we will query your claims once a month to see which claimants are possible Medicare Eligible Recipients. If your Claimant is a Medicare recipient, the Health Insurance Claim Number (HICN) will always be provided on the query results. The Query result file for each RRE code may be viewed in the CMS Account Management Section on the ISO ClaimSearch website. Those specific users with access to these files can obtain this information for your RRE code(s). Please note that the Query results will only show positive results, meaning Medicare Eligible Recipients.
Which reporting fields are required to determine possible Medicare Eligible Claimants?
To identify which claimants are possibly Medicare recipients, each month ISO ClaimSearch will query your submitted claims automatically against the CMS Medicare database. In order to query your claims, the following information is required for each submission:
- Claimant Name
- Date of Birth
- Social Security number (SSN) or Health Insurance Claim Number (HICN)
In addition to these four required fields, the Medicare Eligible Indicator in ISO ClaimSearch reporting must be left un-checked or must be = NO. If your company/office has multiple RRE codes, the RRE code is also required for querying.
Does ISO offer tools to help us find the Social Security Number (SSN) for individuals?
Yes. ISO offers Append-DS, an optional service that helps you obtain Social Security Numbers (SSN) and other public-records information. When you report a claim without a Social Security number, Append-DS automatically triggers a public-records search and includes information found in the Search Result report. Once you get the information you need, you can update the original claim with the missing information and resubmit it to ISO ClaimSearch.
* Please note: ISO ClaimSearch will not automatically add the information you retrieve from Append-DS to the claim, store that information in the ISO ClaimSearch database, or send it to CMS. Companies are responsible for using the information to update their claims. *
If I find claims on my monthly query file that do not belong to my company who should I contact to update this information?
Updating and Preparing Claims
Which claims will ISO ClaimSearch send to CMS?
Claim reporting for CMS is based on the claimant and coverage. Medicare Secondary Payer, Section 111 (CMS) defines reporting requirements by "Plan":
- Liability: third party liability claims
- Includes medical payments for all medical payment coverages
- Workers Compensation
* See Appendix A in the Medicare Secondary Payer Reporting Service User guide for a chart showing which ISO Policy, Coverage and Loss types qualify for CMS Reporting.
Will ISO automatically update the claimants in ISO ClaimSearch with the Medicare Eligible indicator listed on the monthly Query file?
No. It is the responsibility of each company to go into the appropriate claim to add the Medicare eligible indicator = YES and to update the CMS required fields. If you miss any CMS required fields, ISO ClaimSearch will provide warning indicators on your match report. Please note that in most cases, ISO only informs you of missing required fields. A claim may still reject if CMS determines that the data is invalid.
Please note: CMS-required fields may not be the same as ISO ClaimSearch-required fields. A claim may pass the ISO ClaimSearch edits and accepted into the ClaimSearch database. When ISO ClaimSearch forwards the claim to CMS, CMS may reject it if any required fields are missing or invalid.
Can a company have an ORM and a TPOC claim in the same claim file?
Yes, if there are two or more bodily injury coverages on a claimant who is a Medicare recipient, these claims should be reported to CMS:
• If one claim is a med pay claim, the report will be sent with an ORM claim to address medical payments made or committed. The ORM claim will be followed with an ORM termination date, which represents the end of the period of medical payments responsibility.
• If the same claimant is asserting a bodily injury claim, this is considered a TPOC claim that is not sent to CMS until the claim is settled. The claim should be reported to ISO ClaimSearch as soon as possible, and will be reported to CMS upon addition of the TPOC date and amount after settlement. As there are two coverages with two dates, each report is potentially separate. An ORM termination date may be submitted prior to or after the settlement of the BI claim, reported as a TPOC claim.
If CMS rejects a claim, how should my company handle the correction?
If CMS rejects a claim, your company should correct and resubmit the claim to ISO ClaimSearch as an update or replacement. ISO ClaimSearch will then resubmit the claim to CMS during the next quarterly reporting period. Incomplete or erroneous information is returned in a rejection file within 45 days of the file submission date. The file is placed in the Account Management section of ISO ClaimSearch for access by designated company users. The rejection file can be downloaded into a company claims system, or accessed via a spreadsheet for distribution to staff. When reviewing the rejection report please refer to the CMS Disposition and Compliance Codes posted in the User Manuals and Guides section of ISO ClaimSearch.
What action do we take if we are notified by the COBC that our quarterly file exceeded the threshold for errors and will not be released?
If a quarterly claim submission file exceeds 20% rejections, or 5% deletes, the COBC will send an email to the Account Manager that the file exceeded the rejection threshold and will not be processed.
The only way to identify specifically which claims rejected is to ask your EDI rep to release the file. At that time, it will take CMS up to 45 days to process the file and ISO will be able to then post the acknowledgements and rejections to Account Management. Any rejected claim should be corrected before the next quarterly reporting period. At the next period, ISO will automatically re-send any rejected claims which have been updated. CMS will not accept two files in the same quarter, so the corrections are not sent until the next reporting period.
However, if the e-mail from CMS indicating the types of rejections is enough for you to figure out what the problem is, you have the option to request that CMS not release the file and instead, make the corrections to the claims and work with ISO to re-submit a new file to CMS during the same quarter.
Who should we contact if we have any questions about transmission and receipt of files for reporting to CMS?
If I have general questions, who should I contact?