CMS releases updated reporting and recovery thresholds with news on TPOCs

December 16, 2016 / 2 min read

The Centers for Medicare and Medicaid Services (CMS) has released its latest alert regarding its low-dollar reporting and recovery thresholds pertaining to liability (including self-insurance), workers' compensation, and no-fault settlements, judgments, awards, or other payments (settlements).

CMS’s December 12, 2016, alert, Change in Reporting Thresholds for Certain Liability Insurance, No-Fault Insurance, and Workers’ Compensation Settlements, Judgments, Awards, or Other Payments, can be viewed here. This alert provides updated information related to the CMS Section 111 TPOC reporting thresholds.

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This is CMS’s third reporting and recovery thresholds release in the last three months. In a September 26, 2016, alert, CMS outlined its 2016 low-dollar reporting and recovery thresholds. That was followed by a November 15, 2016, alert through which CMS announced its low-dollar thresholds for 2017.

The charts below outline CMS’s current reporting and recovery thresholds and how the thresholds will change starting January 1, 2017.

Section 111 TPOC Reporting Thresholds

With respect to the above, CMS states that reporting of cumulative TPOC amounts at or below the required reporting threshold will be accepted but is not required. Starting January 1, 2017, CMS advises that the CJ07 error code logic will be updated to no longer reject TPOC amounts less than the required reporting thresholds. Until that time, workers' compensation TPOCs less than or equal to $300 and liability TPOCs less than or equal to $1,000 will be rejected unless reported with ORM (ongoing responsibility for medicals). After January 1, 2017, the CJ07 error will be returned only for a liability, workers' compensation, or no-fault claim report where the ORM indicator is set to “N” and the cumulative TPOC amount is zero.

Conditional Payment Recovery Thresholds

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If a settlement falls below the above-stated thresholds, CMS will not seek conditional payment recovery related to that claim.

Practical Considerations

The shifting thresholds have certainly made things interesting over the last few months. Depending on your claim-handling and Section 111 reporting protocols, you may consider updating your internal program to address these updates. The logic in MSP Navigator^® has been updated for Section 111 purposes and will report claims in line with the CMS thresholds.

We will continue to monitor developments and issue updates as warranted. For questions, please contact Mark Popolizio at 786-459-9117 or mpopolizio@iso.com.