The Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) impacts the handling of Workers’ Compensation, Liability, Auto No-Fault, and Self-Insurers claims, defined by CMS as Non-Group Health Plans (NGHP). Section 111 of this Act requires reporting of certain cases and transactions to Medicare.
The primary goal of Mandatory Insurer Reporting is to identify and enforce Medicare’s Secondary Payer (MSP) rights through recovery of conditional payments and ensure that settlements, judgments, and awards adequately protect Medicare’s interests. Fines for non-compliance are $1,000 per claim per day.
Riskonnect provides MMSEA reporting through a partnership with Mitchell Regulatory Reporting Solutions (Mitchell recently acquired Ingenix) , who is certified for submitting MMSEA files.
The Riskonnect functionality is summarized here:
- Riskonnect RIMS provides access to electronic filing services from within our Claims Administration functionality.
- Queries and reports are submitted according to the Client’s assigned schedule
- Data received in response files is attached onto each claim and action items are automatically created and assigned when more information is required.
Q&A Regarding Automated MMSEA Query and Claim Report
How does Riskonnect process MMSEA submissions?
- Riskonnect RMIS allows for capture and storage of all data need to complete MMSEA Queries and Claim Reports.
- A series of special fields and Views of these fields assists adjusters and managers in completing required data.
- Once all required data is complete, Riskonnect submits Queries and Claim Reports through the Mitchell Regulatory Reporting Service for transmission onto CMS (Centers for Medicare and Medicaid Services)
Secondary Payer Detail such as alleged cause of injury, medicare coordination & diagnosis code
What data is required for a successful Query?
• Claimant SSN
• Claimant Last Name
• Claimant First Name
• Claimant Date of Birth
• Claimant Gender
When are Queries Submitted?
Riskonnect submits Queries on the 19th (or previous business day) of each month to our agent (Mitchell Regulatory Reporting Solutions). Queries that are submitted to Mitchell on the 19th are transmitted by Mitchell to CMS on the 20th of each month.
When are Query Responses Received?
CMS advises that Query Responses are received with 14 days of submission to CMS. Actual responses time has been 8 – 9 days.
What is included in a Query Response?
CMS advises if the Query is Accepted (Claimant is Medicare Eligible) or Rejected Claimant is not Medicare Eligible). If Accepted a HICN Number (Medicare’s Health Claim Identification Number) is also returned.
Transmission to CMS details
When are Claim Reports Submitted?
Riskonnect submits Queries to Mitchell on the business day prior to the first day of the RRE’s assigned reporting window. Queries that have been submitted to Mitchell prior to the first day of the RRE’s reporting window are transmitted by Mitchell to CMS on the first day of the reporting window.
When are Claim Report Responses Received?
CMS advises that Claim Responses are received with 45 days of submission to CMS. (Riskonnect has not received responses to our initial Claim Report submissions, so does not have any other data for estimate of response time other the statement from CMS.
Medicare Secondary Payer and Medicare Transmission related lists (at the bottom of the claim form); Related lists that go with the claim in the MMSEA Claim screen capture
Claim with MMSEA links at top of claim form