Ongoing Responsibility for Medicals (ORM) When and What to Report

The following section reviews the requirements for reporting the assumption or establishment of ORM for no-fault insurance, liability insurance (including self-

insurance), and workers’ compensation. Information regarding an RRE’s reporting for the assumption of ORM has been presented in other sections of the NGHP User Guide. This section provides additional policy information. Please see Table 6-13 for a summarized view of the ORM reporting requirements for no-fault, liability insurance (including self- insurance), and workers’ compensation.

The reference to “ongoing” is not related to “ongoing reporting” or repeated reporting of claims under Section 111, but rather to the RRE’s responsibility to pay, on an ongoing basis, for the injured party’s (Medicare beneficiary’s) medicals associated with the claim. This often applies to no-fault and workers’ compensation claims, but may occur in some circumstances with liability insurance (including self-insurance).

The trigger for reporting ORM is the assumption of ORM by the RRE—when the RRE has made a determination to assume responsibility for ORM, or is otherwise required to assume ORM—not when (or after) the first payment for medicals under ORM has

actually been made. Medical payments do not actually have to be paid for ORM reporting to be required.

If an RRE has assumed ORM, the RRE is reimbursing a provider, or the injured party, for specific medical procedures, treatment, services, or devices (doctor’s visit, surgery, ambulance transport, etc.). These medicals are often being paid by the RRE as they are submitted by a provider or injured party. Payments like these are NOT reported

individually under Section 111 as TPOCs (see Section 6.4 for more information on TPOCs). Even when ORM payments are aggregated and paid to a provider or injured party in a single payment, this aggregation does not constitute a TPOC just because it was paid in a “lump sum”. For example, an injured party might incur medical expenses in excess of no-fault insurance (such as automobile Personal Injury Protection (PIP) or Med Pay) shortly after an automobile accident. The RRE may reimburse the provider of these medical services or injured party via one payment since the no-fault limit was already reached, but the payment still reflects ORM, not a TPOC settlement, judgment or award. The dollar amounts for ORM are not reported, just the fact that ORM exists or existed. When ORM ends (a no-fault limit is reached, or the RRE otherwise no longer has ORM, etc.) the RRE reports an ORM Termination Date. If there was no TPOC settlement, judgment, award, or other payment related to the claim (an actual settlement for medicals and/or lost wages, etc.), you do not need to report a TPOC Amount on the claim with ORM. You can just submit the ORM Termination Date.

Reporting for ORM is not a guarantee by the RRE that ongoing medicals will be paid indefinitely or through a particular date; it is simply a report reflecting the responsibility currently assumed. Ongoing responsibility for medicals (including a termination date, where applicable) is to be reported without regard to whether there has also been a separate settlement, judgment, award, or other payment outside of the payment responsibility for ongoing medicals.

It is critical to report ORM claims with information regarding the cause and nature of the illness, injury, or incident associated with the claim. Medicare uses the information submitted in the Alleged Cause of Injury, Incident or Illness (Field 15) and the ICD-9 Diagnosis Codes (starting in Field 18) to determine what specific medical services

claims, if submitted to Medicare, should be paid first by the RRE and considered only for secondary payment by Medicare. The ICD-9 codes provided in these fields must provide enough information for Medicare to identify medical claims related to the underlying Injury, Incident or Illness claim reported by the RRE.

6.7.1 ORM Additional Technical Requirements - When and What to Report

For claims where the liability insurance (including self-insurance), no-fault insurance, or workers’ compensation RRE has assumed ongoing responsibility for medicals – ORM - associated with the claim, two reports under Section 111 are required. The first report is when the RRE assumes ORM. The second is when ORM terminates. In the first report the RRE provides basic information about the claim, including a ‘Y’ in the ORM

Indicator, and the no-fault insurance policy limit (if applicable). In the second report, the RRE provides the ORM Termination Date (date when ongoing responsibility for

medicals has ended) and, if a no-fault case, the date the no-fault policy limit was

exhausted (if applicable). The first report will be an add record and the second report will be an update record. The second report will also have a ‘Y’ in the ORM Indicator.

The RRE does not provide a TPOC Date and TPOC Amount on either ORM report unless there was a settlement, judgment, award, or other payment TPOC amount in

NOTE: In situations where the injured party is a Medicare beneficiary, there has been a settlement, judgment, award, or other payment, and the RRE has not assumed ORM, only

one Section 111 claim report is required after the Total Payment Obligation to Claimant (TPOC) date. The TPOC Date is the date the obligation was established. Please see the description of these fields in the Claim Input File Detail and Auxiliary Record layouts, and the additional explanation in the NGHP User Guide Policy Guidance Chapter (Section 2 - Introduction and Important Terms). The RRE provides the TPOC Date (as defined in Field 80 of the Claim Input File Detail Record) and the TPOC Amount (as defined in Field 81 of the Claim Input File Detail Record) when such a settlement, judgment, award, or other payment occurs. The field descriptions in the record layout explain how to calculate the TPOC Date and TPOC Amount. Note that there is one set of TPOC fields provided on the Detail Record and four more sets of TPOC fields provided on the Auxiliary Record to allow for reporting of multiple TPOC settlements, judgments, awards, or other payments. See also Section 6.4 Reporting Thresholds and Section 6.4.3 Reporting Multiple TPOCs for more information on TPOC reporting requirements. If ORM is started and ended within the same calendar quarter or prior to the current reporting quarter before the initial report of ORM was made, all the reporting may be done on one record. Example: In January, a workers’ compensation claim is opened for an injured employee who is a Medicare beneficiary. The injury is relatively minor, and the ORM terminates in March. Depending upon its specific quarterly submission date, the RRE may only need to report the claim once after the claim is closed and ORM has ended. This record would include a “Y” in the ORM Indicator and an ORM Termination Date. This scenario of reporting both the assumption of ORM and termination of ORM on one add record may also occur if no-fault insurance policy limits are reached shortly after or on the date of incident. A TPOC Date and Amount would also be included in this single report if there was also a separate settlement, judgment, award, or other payment outside of the termination of the ORM.

A value of ‘Y’ in the ORM Indicator means that the claim includes or included ORM. CMS’s key for claims processing actions is knowing an RRE-reported ORM. The ORM Indicator is not an on/off switch. Once “on” (a value of “Y”), it stays “on”. To turn ORM “off” as of a certain date, the RRE sends an ORM Termination Date on an update record, but leaves the ORM Indicator set to ‘Y”. This will indicate that the RRE had ORM from the date of the incident through the ORM Termination date. Zeroes in the ORM Termination Date indicate that there is yet no established end date for the ORM. For claims with ORM, an RRE does NOT make a Section 111 report each time it pays for a medical service for the injured party. The actual amounts paid for specific medical services under the assumption of ORM are not reported. It is only the assumption of coverage that is reported, the fact that ORM has been assumed for a particular claim for a particular period of time.

RREs are NOT to report the same, unchanging ORM claim information each quarter. Once the first report is made and they get back a positive response that the record was accepted they do not need to report again until the ORM has terminated, or there is separate TPOC information to be reported, or another event occurs that triggers the need for an update (see the Event Table in Section 6.6.4).