GRG Client Advisory: Reporting Timeframe Alert for Liability Insurance, No-Fault Insurance, and Workers’ Compensation

To download a pdf of this advisory, please click here.

CMS Alert: Timeliness of reporting for settlements, judgments, awards or other payments when the TPOC¹  date and or the amount is not known when the injury/harm has been identified

The Centers for Medicare and Medicaid Services (“CMS”) posted an alert (the “Alert”) on its website clarifying when Section 111 reporting is required on NGHP settlements. 

CMS defines “Timeliness of Reporting” as when the two following criteria are met:
• The alleged injured/harmed individual to or on whose behalf payment will be made has been identified.
• The TPOC amount for that individual has been identified.

Where these criteria are not met as of the TPOC date, retain documentation establishing when these criteria are met.

This occurs frequently in mass tort/class action cases where a settlement amount has been agreed to, but as of the settlement date, the individuals that are eligible for a portion of the payment have not yet been identified and the amount that will be paid to that individual has not yet been calculated.

CMS provides the following example:

• There is a settlement involving an allegedly defective drug.
• The settlement contains/provides a process for subsequently determining who will be paid and how much.  Consequently, the fact that there will be payment to or on behalf of a particular individual and/or the amount of the settlement, judgment, award or other payment to or on behalf of that individual is not known as of the TPOC date.
• Timeliness of MMSEA Section 111 reporting for a particular Medicare beneficiary will be based upon the date there is a determination both that payment will be made to or on behalf of that beneficiary and a determination of the amount of the settlement, judgment, award or other payment to or on behalf of the beneficiary.

The Garretson Resolution Group is available to answer your questions about the provisions of this Alert.  Please contact us if you would like us to review or help develop your internal processes and to provide training for all parties that are involved in the resolution process.