Updated Section 111 User Guide Provides for Transition to MBIs, ORM Termination Defined

January 03, 2018 By: Daniel Anders

Pursuant to the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, CMS is required to transition all Medicare beneficiaries from the Social Security Number based Health Insurance Claim Numbers (HICNs) to a new identification number called a Medicare Beneficiary Identifier (MBI). The primary purpose of this initiative is to reduce identify theft associated with use of Social Security Numbers in HICNs.

Accordingly, starting in April 2018 CMS will begin to mail new cards with the new Medicare numbers to Medicare beneficiaries. The goal is to issue all new cards by April 2019. For medical providers, there will be a transition period from 4/1/2018 through 12/31/2019 in which either the HICN or MBI will be accepted for processing of payments by Medicare.

Minimal Impact on Section 111 Reporting

Unlike medical providers which must exclusively use the MBI by 1/1/2020, as explained in the updated Section 111 NGHP User Guide, CMS has exempted its Medicare Secondary Payer Reporting processes from exclusive use of the MBI. Consequently, we can continue to report to CMS using a Social Security Number, a HICN or an MBI. In announcing this policy, CMS indicates it has renamed fields labeled “HICN” to “Medicare ID.”

While allowing for continued reporting of HICNs in its Section 111 reporting processes, CMS states that if an MBI has been issued to the claimant, it will return the MBI in the Section 111 response files. We expect then that while not requiring submission of MBIs, CMS nonetheless expects a natural transition to their use for MSP matters over time.

Medicare Conditional Payment Recovery Correspondence to Include Either HICN or MBI

As part of this update, CMS states that its recovery contractors, the Benefits Coordination and Recovery Center (BCRC) and the Commercial Repayment Center (CRC), will use either an HICN or MBI in its correspondence based upon the most recent information provided by the Responsible Reporting Entity (RRE) when creating or updating the MSP record. Again, we expect a natural transition from use of HICNs to MBIs in correspondence from the recovery contractors over the next few years.

The Tower MSP Automation Suite is fully capable of accepting SSNs, HICNs or MBIs for purposes of Section 111 Mandatory Insurer Reporting.

ORM Termination Defined

In addition to updating its User Guide to address the transition to MBIs, CMS also added language to its Section 111 “Policy Guidance” User Guide specifically defining under what circumstances Ongoing Responsibility for Medical (ORM) may be terminated. The revised Section 6.3.2 states as follows:

6.3.2 ORM Termination

When ORM ends, the RRE should report the date that ORM terminated and should NOT delete the record. Please note that a TPOC amount is not required to report an ORM termination date. An ORM termination date should not be submitted as long as the ORM is subject to reopening or otherwise subject to an additional request for payment. An ORM termination date should only be submitted if one of the following criteria has been met:

  • Where there is no practical likelihood of associated future medical treatment, an RREs may submit a termination date for ORM if it maintains a statement (hard copy or electronic) signed by the beneficiary’s treating physician that no additional medical items and/or services associated with the claimed injuries will be required;
  • Where the insurer’s responsibility for ORM has been terminated under applicable state law associated with the insurance contract;
  • Where the insurer’s responsibility for ORM has been terminated per the terms of the pertinent insurance contract, such as maximum coverage benefits.

While now formalized, this ORM termination guidance had previously been provided by CMS, either in other sections of the User Guide or in guidance provided outside the guide, such as through CMS Townhall calls.

Notably, advocacy efforts have been made with CMS to request an expansion of the ORM termination criteria. Such expansion would, for example, provide for ORM termination if no medical has been paid on a claim over a certain number of years. The benefit of allowing for a greater number of claims to terminate ORM would be less of an administrative burden for employers and carriers and a reduction in denials of payment by Medicare for charges completely unrelated to reported claims.

Unfortunately, CMS has thus far been unresponsive to expanding its definition of ORM termination, choosing instead to work out improper denial of payments and unwarranted conditional payment recovery efforts on the back-end rather than addressing the quality of the data reported to CMS on the front-end.

The Updated Section 111 User Guide, Version 5.3, may be found here.

Please contact Dan Anders at Daniel.anders@towermsa.com or (888) 331-4941 with any questions regarding the updated guide.

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