In order for Responsible Reporting Entities to meet Medicare Section 111 Mandatory Insurer Reporting Requirements they may be required to report that their plan is primary to Medicare by setting the Ongoing Responsibility for Medicals (ORM) flag to 'Y'.  When the insurer reports under Mandatory Insurer Reporting that their plan is primary, the Medicare beneficiary's provider attempts to bill Medicare will be denied.  If provider, or the Medicare intermediary, mistakenly bills Medicare, then the Insurer will receive a reimbursement demand from Medicare.  If both the RRE and Medicare paid, Medicare will seek recovery for their payment from the provider.  See Medicare Duplicate Primary Payment.

In the Section 111 User Guide, CMS states that, "The trigger for reporting ORM is the assumption of ORM by the RRE – when the RRE has made a determination to assume responsibility for ORM or is otherwise required to assume ORM – not when or after the first payment for medicals under ORM has actually been made. Medical payments do not actually have to be paid on the claim for ORM reporting to be required."

If the Responsible Reporting Entity has accepted ORM and they make a lump-sum distribution (regardless as to whether that lump-sum was as an annuity or cash), the RRE must also report a TPOC (see below).

Once the Responsible Reporting Entity has reported ORM under Section 111 that they have ongoing responsibility for medicals, Medicare will assume that plan is primary until the RRE reports otherwise by closing the period of primary coverage.  The RRE signals the end of ORM by leaving the ORM indicator set to 'Y' and submitting the ORM Termination Date.  If the insurance type is 'No-Fault', then the RRE must submit the a date for the No-Fault Exhaust Date as well.

If the RRE has only made a one-time settlement with the beneficiary, then the RRE should report a Total Payment Obligation to Claimant (TPOC) amount.  See Medicare Section 111 Mandatory Insurer Reporting Requirements for reporting TPOC.

If the RRE is a hospital, it is very important to correctly report risk management write-offs.  See Medicare Current News and Updates for information and review the article about Hospital Write-offs.

Still Confused?

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