MMSEA Reporting Question

Medicare Set-Aside Blog on January 11, 2010
Posted by


I am reading the CMS townhall transcripts are am a little confused. Are they saying we need to report all WC claims that involve a Medicare beneficiary? I heard $600 was the threshold?


This question is actually a little tricky. Through 12/31/2011, WC TPOCs (settlements) of $0 – $5K are exempt from reporting; however, RREs are not required to adhere to the thresholds if the RRE also has ongoing responsibility for medicals (ORM). Many are saying that if there is ORM, then it’s easier for them to go ahead and report all TPOCs despite the thresholds as a matter of course. Basically, it’s one less variable to consider so that is what makes reporting everything easier. As long as there is ORM, reporting TPOCs of all amounts is acceptable.


I think you are thinking of where the threshold eventually ends up down the road – $0-$600 is the threshold for exemption from 1/1/13 – 12/31/13. Section 11.4 of the User Guide lays it out, but honestly, I refer to it every time there is a question. It’s not an easy read.


The most typical course for a WC claim is going to be


1) RRE submits an Add Record – reporting ORM

2) RRE submits an Update Record – reporting ORM termination + TPOC


If a denied claim and ORM is never accepted, but they settle, then there would just be one Add Record and thresholds would apply. The threshold amount now is $5K, but slowly decreases until 1/1/14 when thresholds no longer apply and all TPOCs must be reported.


I hope that helps/answers the question…