Medicare Basics! (Key Concepts and Definitions)
This acronym stands for Medicare Advantage Plan, a type of Medicare administered by private insurers like UnitedHealthcare or BCBS.
What is MAP?
This document from the accident scene often contains claimant name, DOB, address, and injury details.
What is the police report?
Medicare compliance requirements should be completed within this timeframe from claim assignment, or the reason for delay must be documented.
What is 90 days?
*If delayed - time of settlement
Civil monetary penalties for Section 111 violations can reach up to this dollar amount per day of non-compliance.
What is $1,000 per day?
This recovery center manages conditional payment liens for Traditional Medicare Part A/B.
What is BCRC (Benefits Coordination & Recovery Center)?
This is the primary tool to search for missing Medicare data fields, and it's the lowest cost option if run within the first 6 months.
What is LexisNexis (or LexisNexis Claim Information Search)?
This is the recommended Medicare compliance option as it ensures system queries will work and we will get Medicare information.
What are data fields (or required data fields / Option A)?
If the claimant is attorney-represented and refuses to provide Medicare data, you must do this when sending written requests for information.
What is copy (cc) the claimant?
This acronym stands for Total Payment Obligation to Claimant—the settlement amount and date we report to Medicare.
What is TPOC?
This claims database helps locate prior or post losses and may contain Medicare eligibility information.
What is ISO (or ISO ClaimSearch)?
This form should be obtained when someone states they are not a US citizen or for minors when a social is not available.
What is a signed Medicare declaration letter/form (or make 3x attempts)?
Claims where coverage or liability is denied with no payment expected fall under this compliance category.
What are Medicare compliance exceptions?
This federal agency administers the Medicare program and issues Section 111 mandatory reporting requirements.
What is CMS (Centers for Medicare & Medicaid Services)?
Not only needed for claim evaluation, but these documents can identify missing data fields and other insurance information.
What are Medical Records?
If you cannot get the data fields, signed declaration form, or written refusal; document this many attempts to obtain required Medicare information.
What is 3 (three) documented attempts?
This is where you should go when you have a Medicare question or are unsure on required steps.
What is Knowledge Center?
This term describes ongoing responsibility to pay medical bills and is only applicable to Casualty on homeowner liability MedPay claims.
What is ORM (Ongoing Responsibility for Medicals)?
After litigation is filed, these legal tools—including interrogatories and document requests—can be used to obtain missing Medicare information.
What is discovery (or discovery requests)?
Federal law requires settlement information to be reported to CMS within this many days of the TPOC date or ORM assumption to avoid penalties.
What is 365 days (or 1 year)?
If the system does NOT automatically send the Medicare Declaration letter, you will receive this type of system notification in Navigator.
What is a DAR failure?