Liability Insurance (Including Self-Insurance), No-Fault Insurance and Workers' Compensation - Revised User Guide Version 3.4

The Centers for Medicare and Medicaid Services (“CMS”) posted Version 3.4 of the User Guide, dated July 3, 2012, (“Version 3.4”) on its website. Version 3.4 includes the guidance that CMS has provided in various alerts since the previous User Guide was published on December 16, 2011. In its latest User Guide version, CMS divides the User Guide into five separate, but related chapters; incorporating previously issued alert guidance. Version 3.4 does not introduce any significant policy changes. A brief summary of the five chapters follows:

Chapter I - Introduction and Overview

• Introduces MMSEA terms and includes the MSP statutory and regulatory provisions
• Includes the overview of Medicare entitlement, eligibility and enrollment
• Provides general overview of who must report, what must be reported and how to report

Chapter II - Registration Procedures

• Explains how to register and how to make changes, when needed, after registration
• Training and Education

Chapter III - Policy Guidance

• Who must report (Section 7 from Version 3.3 is now at Section 6 of Version 3.4)
• What must be reported (Section 11.10.2 from Version 3.3 is now at Section 6.5.1 of Version 3.4)
• On-going responsibility for medicals (“ORM”) and Total Payment Obligation to Claimant (“TPOC”) reporting requirements
• Threshold reporting provisions

Chapter IV - Technical Information

• Provides technical information on how to report
• Explains the data exchange process
• Includes the submission time frames
• Section 12 of Version 3.4 states that the signed Profile Report should now be returned to the EDI Representative

Chapter V – Appendices

• Appendix A – Claim input file layout
• Appendix B – Tax identification number (“TIN”) reference file layout
• Appendix C – Claim response file layout
• Appendix D – TIN reference response file layout
• Appendix E – HIPAA eligibility wrapper (“HEW”) query file input and response file layouts
• Appendix F – Disposition, error and compliance flag codes
• Appendix G – MMSEA Section 111 statutory language
• Appendix H – MMSEA Section 111 definitions and reporting responsibilities
• Appendix I – Excluded ICD – 9 Codes
• Appendix J – Section 111 acronym list
• Appendix K – Alerts: This information is new to the User Guide. It includes a list of Alerts previously issued by CMS

Please let us know if you have any questions about where information from Version 3.3 is located in Version 3.4. If you have any questions about Medicare compliance or about the new User Guide please contact Marlene Wilson at Garretson Resolution Group at 704-559-4300 or at mwilson@garretsongroup.com.