Medicare Query Function
This is how often a claim is sent for query
Monthly
This is the "entity" responsible to pay claims to/on behalf of Medicare beneficiaries
Responsible Reporting Entity RRE
A Conditional Payment Notice requires a response by this date.
Response Due Date
WC - Claimant age 70 - Medicare Beneficiary. Fell down stairs while moving ladder for employer, fractured hip, pain continues, ongoing RX with need for future care. Client requires CMS approval of allocation.
Settlement $15,000, MSA $15,000This type of allocation is required for this claim.
Medicare Set Aside WCMSA
This is what the acronym TPOC stands for
Total Payment Obligation to Claimant
These are the "Big 5" data elements required for the Medicare Query process
Claimant's legal first name (as shown on SS card)
Claimant's legal last name (as shown on SS card)
Date of birth
Gender
Social Security Number
This is accepted when a medical payment or bodily injury payment/settlement is made on a claim
Ongoing Responsibility for Medical ORM
Failure to respond to a Conditional Payment will result in this type of referral
US Department of Treasury
Liability – Claimant age 67 – Medicare Beneficiary. While at insured’s office, sat in a chair, roller came out and chair tipped throwing claimant on the floor. Insured knew prior that chair was broken. Suffered contusions, R ankle fracture, required surgery – ORIF. Good recovery but may need future surgery to remove hardware.
BI settlement $85,000, Future medical $25,000
This type of allocation is recommended for this claim.
Claim Settlement Allocation
This is what the TPOC Amount represents
TPOC Amount represents the total payment obligation to, or on behalf of, the claimant
Settlement/judgment/award/impairment/or other payment intended to resolve or partially resolve a claim
Once the claim has been sent for query, this is one of the two possible Medicare Eligibility query responses added to the claim notes
Unknown
or
Yes
True or False:
Once ORM is "Yes" it can never be changed to "No"
True -
The only way to report ORM no longer exists is to enter/report an ORM Termination Date
To dispute Conditional Payments on a WORK COMP claim, this type of authorization is required
Letter of Authority
WC – Claimant age 65 – Medicare Beneficiary.
Compensable claim, herniated disc, surgery but continues to c/o radiating pain/numbness in legs; will need ongoing pain meds. Possible fusion in future but claimant refuses to undergo another surgery. Client DOES NOT require CMS approval of allocation.
Settlement $125,000, Allocation $85,000
This type of allocation is recommended for this claim.
Evidence Based Medicare Set Aside EBiMSA
REQUIRES Funds structured through Chronovo AND professional administered by Ametros
Work comp PPD settlement $100,000
MSA $50,000
Disputed TTD $10,000
Annuity purchased for $30,000
This is the TPOC Amount
$100,000 PPD + $50,000 MSA + $10,000 disputed TTD
TPOC is: PPD + TOTAL PAYOUT of the annuity
The cost of the annuity is not factored into TPOC
When a claim is queried and the response received is yes, iCEBAR sends a diary requiring adjuster to enter this information.
SCHIP Body Part(s)
ORM Termination IS / IS NOT the date the claim was administratively closed
IS NOT
ORM Termination date IS NOT the date the claim was administratively closed.
To dispute Conditional Payments on a LIABILITY claim, this type of authorization is required
Beneficiary Proof of Representation
Liability – Claimant age 90 – Medicare Beneficiary. Our insured backed into claimant’s vehicle. Claimant suffered soft tissue injury, treated with chiro. Released from care with no expectation of future care.
BI Settlement $3,000
This is an appropriate ALTERNATIVE to a set aside/allocation
Protective Language
When paying out an impairment rating (settlement) in installments to close out the indemnity portion of the claim and leaving medical open.
Should impairment payment be entered as TPOC?
Yes or No
No – There is no TPOC if paying in installments and medical is left open.
HOWEVER, if paying in a lump sum the lump sum IS considered TPOC.
According to CMS, TPOC reflects a “one time” or “lump sum” settlement, judgment, award, impairment rating intended to resolve or partially resolve a claim.
When a claimant is 65 and the query comes back as Unknown, this is the next step in the process
Confirm data elements are correct
OR
Request Medicare Eligibility Inquiry MEI from ECS
This is one of the criteria necessary to terminate ORM
Settlement, Judgment, Award, Impairment
Statute of limitations expiration
Letter from claimant's treating physician indicating no further medical care is warranted/anticipated
Failure to address Conditional Payments results in a Referral to this US Department
US Department of Treasury
WC – Claimant age 65 – Medicare Beneficiary. Lifting box and suffered injury to lumbar, diagnosed with bulging disc. Underwent physical therapy and symptoms resolved.
Settlement $10,000
This is an appropriate ALTERNATIVE to a set aside/allocation
Letter from the treating physician stating no future care is warranted or anticipated
OR
Protective Language
Conditional payments $500
This is the TPOC amount
TPOC = $1,500
$1,000 settlement + $500 Conditional payments
Remember: TPOC is total amount paid to or on behalf of the claimant