CMS Updates Mandatory Reporting User Guide, Providing New TPOC Timelines and Amounts on No-Fault, Liability, Work Comp Claims

Posted by Rafael Gonzalez on Jan 10, 2017 10:19:23 AM

On January 3, 2017, the Centers for Medicare and Medicaid Services (CMS) published Version 5.2 of the Section 111 NGHP User Guide. The Mandatory Insurer Reporting (MIR) updates listed below have been made to Chapter III, Policy Guidance.

As previously announced by CMS, Section 111 reporting has changed the minimum reportable Total Payment Obligation to the Claimant (TPOC) amounts for liability insurance (including self-insurance), no-fault insurance, and workers’ compensation claims, as follows:

  • Liability is changing from $1000 to $750 for TPOC Dates of 1/1/2017 and subsequent.
  • No-Fault is changing from $0 to $750 for TPOC Dates of 10/1/2016 and subsequent.
  • Workers’ Compensation is changing from $300 to $750 for TPOC Dates of 10/1/2016 and subsequent.

Therefore, TPOC amounts that exceed these thresholds must be reported. However, TPOC amounts less than the specified threshold may be reported and will be accepted. If such less than specified TPOCs are reported, no CJ07 error will be produced as the logic for the CJ07 error has been changed such that a TPOC of any amount will be accepted for all types of TPOCs, including liability TPOCs. The CJ07 error will continue to be returned for a liability, workers’ compensation, or no-fault claim report where the ORM Indicator is set to “N” and the cumulative TPOC amount is zero.

What is TPOC?

TPOC refers to the dollar amount of a settlement, judgment, award, or other payment in addition to or apart from Ongoing Responsibility for Medical (ORM). “A TPOC generally reflects a one-time or lump sum settlement, judgment, award, or other payment intended to resolve or partially resolve a claim. It is the dollar amount of the total payment obligation to, or on behalf of the injured party in connection with the settlement, judgment, award, or other payment.”

The TPOC date is not necessarily the payment date or check issue date. “The TPOC date is the date the payment obligation was established. This is the date the obligation is signed if there is a written agreement, unless court approval is required. If court approval is required, it is the later of the date the obligation is signed or the date of court approval. If there is no written agreement, it is the date the payment (or first payment if there will be multiple payments) is issued.”

These latest changes can be found at https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Non-Group-Health-Plans/Downloads/New-Downloads/NGHPUserGuideVer52Ch3Policy.pdf.

TPOC Reporting Requirements 

The following tables, found in Chapter 6 of Chapter III of Version 5.2 of the Section 111 NHGP User Guide, summarize the historical and current state of MIR for no-fault, liability and workers compensation TPOC reportable amounts and dates.

TPOC Reporting Requirements Summary

Insurance Type

Reportable TPOC Dates

Reportable Amounts

Threshold Applicable

No-Fault

October 1, 2010 & subsequent

 

Cumulative TPOC Amount that exceeds threshold

Yes

 

Liability insurance (including self- insurance)

October 1, 2011 & subsequent

Cumulative TPOC Amount that exceeds threshold

Yes

 

Workers’ Compensation

October 1, 2010 & subsequent

Cumulative TPOC Amount that exceeds threshold

Yes


No-Fault TPOC Threshold Timelines and Amounts 

Reporting Required for Cumulative Total TPOC Amount(s)

Reporting Optional for Cumulative Total TPOC Amount(s)

Most Recent TPOC Date is on or between

Reporting Required Quarter Beginning

Greater than $750

Greater than $0 through $750

 

October 1, 2016 or after

January 1, 2017


Liability TPOC Threshold Timelines and Amounts

Reporting Required for Cumulative Total TPOC Amount(s)

Reporting Optional for Cumulative Total TPOC Amount(s)

Most Recent TPOC Date is on or between

Reporting Required Quarter Beginning

Greater than $100,000

Greater than $5,000 through $100,000

 

October 1, 2011 to March 31, 2012

 

January 1, 2012

 

Greater than $50,000

 

Greater than $5,000 through $50,000

 

April 1, 2012 to June 30, 2012

 

July 1, 2012

 

Greater than $25,000

Greater than $5,000 through $25,000

 

July 1, 2012 to September 30, 2012

 

October 1, 2012

 

Greater than $5,000

 

Greater than $300 through $5,000

 

October 1, 2012 to Sept. 30, 2013

 

January 1, 2013

 

Greater than $2,000

 

Greater than $300 through $2,000

 

October 1, 2013 to Sept. 30, 2014

 

January 1, 2014

 

Greater than $1,000

 

NA

 

October 1, 2014 to Dec. 31, 2016

 

January 1, 2015

 

Greater than $750

Greater than $0 through $750

January 1, 2017 or after

 

April 1, 2017


Work Comp TPOC Threshold Timelines and Amounts

Reporting Required for Cumulative Total TPOC Amount(s)

Reporting Optional for Cumulative Total TPOC Amount(s)

Most Recent TPOC Date is on or between

Reporting Required Quarter Beginning

Greater than $5,000

Greater than $300 through $5,000

October 1, 2010 to Sept., 30, 2013

January 1, 2011

 

Greater than $2,000

 

Greater than $300 through $2,000

October 1, 2013 to Sept. 30, 2014

January 1, 2014

 

Greater than $300

 

NA

 

October 1, 2014 or after

 

January 1, 2015

Greater than $750

Greater than $0 through $750

 

October 1, 2016 or after

 

January 1, 2017


About Rafael Gonzalez

Rafael Gonzalez, Esq. is President of Flagship Services Group, the only national Medicare Secondary Payer services provider focusing on and offering comprehensive mandatory reporting, conditional payments, and set aside allocation compliance services to the property and casualty insurance industry. He speaks and writes on mandatory insurer reporting, conditional payment resolution, set aside allocations, CMS approval, and MSA and SNT professional administration, as well as the interplay and effect of these processes and systems and the Affordable Care Act throughout the country. Rafael blogs on these topics at Medicare Compliance for P&C Insurers at http://www.flagshipservicesgroup.com/blog. He can be reached at rgonzalez@flagshipsgi.com or 813.967.7598

Topics: CMS

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