Transitional Relationships and Roles under Section 111

Regulatory guidelines for MSP and MMSEA compliance are frequently changing, and it is no surprise that the reach of the types of entities impacted by these laws are constantly changing as well.  Multiple entities can be involved in the process of managing and handling claims, such as insurance carriers, employers, and third party administrators. In reference to MMSEA Section 111, reporting agents also come into play.  With such hefty fines threatened with non-compliance ($1000 per claim/per day), it is important for everyone involved in this process to understand their roles and obligations. 

Section 111 reporting has become an important factor to consider when a transition in these relationships occurs. Examples of these types of transitions include switching TPAs or an acquisition of one RRE by another RRE. Insurance carriers and employers who are RREs now need to consider a new reporting structure and/or process in order to remain compliant with Section 111 guidelines during the transition. Points to consider include:

  • Which claims are involved in the take over process?
  • Are any additional RRE IDs required and/or do any need to be placed in an inactive status?  
  • Is there a change in reporting agent?
  • Has there been a change in RRE responsibility?
  • When will the change take place?
  • What is the RRE’s quarterly reporting schedule?

Transitional Relationship Scenario #1- New TPA
When transitioning claims from one TPA to another, an RRE will need to identify which claims will be involved in the takeover process.   For example, will a new TPA be handling only new claims for an RRE on a go-forward basis or will they also be taking over existing claims? If only new claims will be moving to the new TPA, it is possible that a new RRE ID will be needed, depending on how each TPA is handling Section 111 reporting.  Section 8.2 of the NGHP User Guide states the following in regard to multiple RRE IDs: “Only one Claim Input File may be submitted on a quarterly basis for each RRE ID. Due to corporate organization, claim system structures, data processing systems, data centers and agents that may be used for data submission, you may want to submit more than one Claim Input File to the COBC on a quarterly basis and therefore will need more than one RRE ID in order to do so.”

On the other hand, an RRE may have the option to discontinue using a previously established RRE ID if claims will now be administered by TPAs utilizing the same reporting agent.  If multiple RRE IDs were obtained, the RRE may be able to condense reporting under fewer RRE IDs based on the new reporting structure.

Transitional Relationship Scenario #2- New Reporting Agent
If an RRE is changing reporting agents, the new agent should continue to submit files under the RRE’s existing RRE ID(s). The COBC cannot supply a file of previously submitted and accepted records for the RRE IDs.  The RRE will need to ensure the new reporting agent is granted access to the RRE ID via the COBSW by inviting the appropriate members of the new agent as account designees. If applicable, the new reporting agent may take on the account manager role, for which a written request will need to be made to the EDI Representative. 

Section 8.3.3 of the NGHP User Guide states, “Updates to other information such as changing reporting agent, changing from one file transmission method to another, changing from DDE to a file transmission method, overriding the 500 claim limit for DDE, or changing the TIN associated with the RRE ID must be requested through your EDI Representative. You must also contact your EDI Representative to change your Authorized Representative or Account Manager to a different individual.”

The new agent will only be able to submit and access files for the RRE once these changes are made.  In addition, the account manager should ensure account designees associated with the previous reporting agent or associated organizations are removed.

Transitional Relationship Scenario #3- Change in RRE
It is also possible for a change in RRE to occur.   According to CMS, the transition of reporting responsibility in whole or in part, from one RRE to another is the responsibility of the entities involved.  If this occurs, it is important to ensure that the COBC no longer expects claims to be submitted under existing RRE ID(s) by submitting a written request via email to the assigned EDI Representative requesting that the RRE ID be placed in an inactive status.  If production files were never submitted under the RRE ID, then the ID can be deleted.

Section 8.3.2 of the NGHP User Guide states, “the new RRE may register for a new RRE ID or report the transitioned claim records under one of its existing RRE IDs. The new RRE may update and delete records previously submitted by the former RRE under a different RRE ID as long as the key fields for the records match. Key fields are injured party HICN or SSN, CMS date of incident, plan insurance type (liability, no-fault, or workers’ compensation) and ORM indicator. The RRE IDs do not need to match. The former RRE must NOT delete previously submitted and accepted records. If the ORM previously reported has ended, then update transactions should be sent with applicable ORM Termination Dates. The new RRE may send add transactions for new ORM and new claims with TPOCs or update transactions to change existing records with new information such as the new RRE TIN.”

It is important that the RRE will need to identify whether the date of any transition will interfere with their quarterly reporting schedule.  If there is any risk that claims may not be submitted through the query process or for the quarterly submission timely, they should notify the EDI Representative regarding the details of the transition or takeover process and coordinate the proper steps that should be taken to avoid any potential risk.

Whether the RRE role is transitioning to you or away from you, you will have a role to play within this process. CMS makes this clear by stating that the “transition of reporting responsibility from one RRE to another is the responsibility of the RREs involved.” It is important to understand the tasks involved, your responsibility in the process, and any issues with regard to the timing of the change. Communication between the RREs, reporting agents, and the COBC is essential and should be coordinated to ensure a smooth transition. The transition of claim responsibility from one RRE to another can be a complex task with several moving parts but with careful synchronization and communication, the daunting task can be accomplished. 

Regardless of the type of transition taking place, changes with respect to Section 111 can be complicated but must be effectuated correctly or noncompliance can occur. PMSI recommends that you consult with your reporting agent, CMS, COBC, as well as the User Guide and/or any other available written guidance from CMS prior to undertaking any of these transitions.

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