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CMS Claim Reports

Which claims need to be reported?
  • All claims that were on the open/active claims list as of 01/01/2010
    • At least $750.00 medical costs have been paid to medical providers OR the employee has been off work more than 7 days (LT claims)
    • Claimant is eligible to receive MEDICARE
    • To see how to determine MEDICARE eligibility please review "CMS Query Procedures".
  • All other "Eligible Claims" may be excluded from CMS reporting until such time they become active/open again at which time they must be reported with the next quarterly reports. (see section 11.9 of the CMS Users Guide v3.1 for more information)
    • To exclude a claim check the box "Exclude from CMS reporting" on the Injury Info tab under Edit --> Claim Data in the claim area.  
    • DO NOT check the "Exclude from CMS reporting" box on open claims.  If you are not going to report a claim yet and it is still open just leave it unchecked and unreported in the system so it will show up on the "Export Eligible Claims" report next quarter.
    • DO NOT check the "Exclude from CMS reporting" box until all responses to reports that have been sent to CMS have returned. The requirement to report to CMS does not end until the MSP_TERM date is accepted by CMS and has been shown in the response data from the reports that have been filed.
    • If you have checked the "Exclude from CMS reporting" box on a closed claim and you reopen the claim, the system will "un-exclude" the claim so it will be on the "Export Eligible Claims" report next quarter.
When do I need to report settlements (LSS) ?
  • When the LSS payment has settled the medical portion of the claim.  You do not report settlements that settled only the indemnity portion of the claim.
  • When the settlement occurred after 10/1/2010 and was greater than $300.00
  • You MUST fill in the ORM Term date with the settlement date in addition to the TPOC1 Date and TPOC1 amount
  • Settlements prior to 10/1/2010 do not need to be reported (CMS will accept the data if sent).  The claim still needs to be reported with an ORM Term date as of the settlement date and the TPOC 1 fields can remain empty.
What do I do when I receive a settlement?
  • Fill in the "Settled Medical" and or the "Settled Indemnity" dates on the "Claim Info" tab (tab #2) under Edit --> Claim Data menu in the claim.
  • Change the Claim Certification to C7 or N7 on the "Claim Info" tab under Edit --> Claim Data.
  • File either a NEW (if no previous report filed) or CHANGE (previous report accepted by CMS with a 01 or 02 response) report on the EDI Info --> CMS Reports menu that includes the ORM Term Date, TPOC 1 Date and the TPOC 1 amount. 
When do I file "Change Reports" ?
  • If a "New Report" has been accepted by CMS with a result of 01 or 02 you must file a change report in the next quarter when:
    • The claimant dies (claim related or not) - file a change report with only the ORM Term Date as of the Date of Death
    • Allowed conditions (ICD-9 Codes) have been added or removed from the claim
    • The claim is overturned or denied
    • The claim is settled
    • An attorney is added or changed in the claim
    • Some other legal reason that the medical portion of the workers' comp claim is settled
  • DO NOT file change reports for claims where CMS has not given a result of 01 or 02 for a "New Report" from a previous quarter.  If a result of 03 or SP for the last "New Report" filed in the claim is received,  another "New Report" must be filed in the next quarterly report period if the claim still meets the reporting criteria and the claim is still on the "Active / Open" claims list.  
When do I file "Delete Reports" ?
  • Never
How can I see / print the reports I am going to send?
  • From the EDI --> CMS Claim Reports menu run the "Export Eligible Claims" report.  Anything with a value in the "Current Rpt" column will be sent to CMS in the next quarterly submission.
How can I see the results from the last quarterly submission?
  • From the EDI --> CMS Claim Reports menu run the "Export Eligible Claims" report.  The most recent results (the only results that count) will be in the "Last RPT", "Last Result" and "Result Date" columns.
  • Results for a specific claim can be seen in the claim screen under EDI Info --> CMS Claim Reports on the results tab for the specific report in question.
  • All results for a period can be exported to excel from the Menu - EDI --> CMS Claim Reports --> Export Results menu selection.  This report shows all of the data that came back from CMS with the error and status codes.  This report is generally only used when a result code of SP is returned for multiple claims or when trying to audit CMS reporting.  A result code of SP for one claim should be reviewed in the claim that received the result.    
Does someone who was just awarded SSDI need to be put on the report even though they weren't on the last query and don't show up as an eligible claim?
  • If the employee has a HICN number that is not being returned from the CMS query process.  Add the HICN number in the employee's HRMS record by looking up the employee by using CTRL-H (entering SSN or last name) and using the menu selection "Edit --> Employee data".  CMS reports CAN NOT be filed without the HICN number on file in the HRMS record.
  • Run the "Export Eligible Claims" report to determine if any of the claimant's claims are eligible to be reported.  If the employee's claims appear on the report and the claims meet the reporting criteria - report as normal.
When do I send the claim reports to CMS?
  • Reports must be sent during the reporting period for the RRE. (see the Compensate Calendar or a list of period dates)
  • The report file must be accepted by CMS and begin processing by the end of the reporting period for the RRE or they will consider the reports to be late and the CMS rep will need to be contacted to release the file.
What if I have nothing to report for an RRE in a quarter?
  • An e-mail needs to be sent to the CMS rep with the RRE number stating there is nothing to report for the quarter.  No files need to be submitted electronically.
How long does it take for results to come back from CMS?
  • CMS results can take up to 45 days to return.
  • The RRE's authorized representative and account manager are notified by e-mail when the claim file starts and finishes processing.  The account designee is not notified of anything by CMS and is dependent on being notified by the account manager.
  • Periodically attempting to download results or checking the CMS web site are alternative to being notified by e-mail.
How does the Date of Death get filled in on the "Export Eligible Claims"?
  • Update the Date of Death in the employee's HRMS record by using the menu selection Edit --> Employee Data from the Employee HRMS data screen.
  • Date of Death in the employee record is not related to any specific claim and should be considered the date the employee died - claim related or not. - updating the data in the HRMS record will make the date appear on the report next to all claims for that employee (matched by SSN).
  • DO NOT update the Date of Death in the claim record if the death did not occur as a result of the workers' comp injury.  Updating the Date of Death in the claim record will make it appear as if the claim is a death claim and will be confusing in future audits.
When do I run the "Export Results"?
  • Never - the option on the menu is for diagnosing problems with CMS reports to see what raw data has been received in a period of time.
When do I run the "Export Pending Reports"?
  • Never - the option allows users to see what CMS claim reports are pending and have not yet been sent - a better report to run would be the "Export Eligible Claims" and look for rows with a value in the current report column and no sent date.  This report also will show all reports that have been sent but no response has been received (value in current report and the sent date columns). 
Additional information on CMS reporting is found in the CMS Users Guide for Non-Group Health reporters.