Consequence of not reporting medicare on cms form

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U.S. Dept. of Health & Human Services

CMS Reporting a Case

Guidance for Medicare beneficiaries, through their attorney or otherwise, notifying Medicare when a claim is made against an alleged tortfeasor with liability insurance (including self-insurance), no-fault insurance or against Workers’ Compensation (WC).

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: October 16, 2019

Medicare beneficiaries, through their attorney or otherwise, must notify Medicare when a claim is made against an alleged tortfeasor with liability insurance (including self-insurance), no-fault insurance or against Workers’ Compensation (WC). This obligation is fulfilled by reporting the case in the Medicare Secondary Payor Recovery Portal (MSPRP) or by contacting the Benefits Coordination & Recovery Center (BCRC). Contact information for the BCRC may be obtained by clicking the Contacts link.

When reporting a case in the MSPRP or contacting the BCRC, the following information is needed:

• Full Name
• Medicare Number
• Gender and Date of Birth
• Complete Address and Phone Number

• Date of Injury/Accident, or Date of First Exposure, Ingestion or Implant
• Description of Alleged Injury, Illness or Harm
• Type of Claim (Liability Insurance, No-Fault Insurance, Workers’ Compensation)
• Insurer or Workers’ Compensation Name and Address

• Attorney or Law Firm Name
• Complete Address and Phone Number

Once all information has been obtained, the BCRC will apply it to Medicare’s record. If Medicare is pursuing recovery directly from the beneficiary, the BCRC will issue a Rights and Responsibilities letter and brochure. The Rights and Responsibilities letter is mailed to all parties associated with the case. The Rights and Responsibilities letter explains:

• What happens when the beneficiary has Medicare and files an insurance or workers’ compensation claim;
• What information is needed from the beneficiary;
• What information can be expected from the BCRC and when;
• How and when the beneficiary is able to elect a simple, fixed-percentage option for repayment; and
• How to contact the BCRC

Please click the Medicare’s Recovery Process link to access a copy of the Rights and Responsibilities letter and brochure. Note: If Medicare is pursuing recovery directly from the insurer/workers’ compensation entity, the Commercial Repayment Center (CRC) will send recovery correspondence to the insurer/workers’ compensation entity and copy the beneficiary and beneficiary’s attorney or other representative. The beneficiary does not need to take any action on this correspondence. Click the Insurer NGHP Recovery link for more information on insurer recovery.

Liability Insurance (Including Self-Insurance): Exposure, Ingestion, and Implantation Issues and December 5, 1980

Medicare has consistently applied the Medicare Secondary Payer (MSP) provision for liability insurance (including self-insurance) effective 12/5/1980. As a matter of policy, Medicare does not claim a MSP liability insurance based recovery claim against settlements, judgments, awards, or other payments, where the date of incident (DOI) occurred before 12/5/1980.

When a case involves continued exposure to an environmental hazard, or continued ingestion of a particular substance, Medicare focuses on the date of last exposure or ingestion to determine whether the exposure or ingestion occurred on or after 12/5/1980. Similarly, in cases involving ruptured implants that allegedly led to a toxic exposure, the exposure guidance or date of last exposure is used. For non-ruptured implanted medical devices, Medicare focuses on the date the implant was removed. (Note: The term “exposure” refers to the claimant’s actual physical exposure to the alleged environmental toxin, not the defendant’s legal exposure to liability.)

When reporting a potential settlement, judgment, award, or other payment related to exposure, ingestion, or implantation, the date of first exposure/date of first ingestion/date of implantation is the date that MUST be reported as the DOI.

For further details regarding this topic, please refer to the Liability Insurance (Including Self-Insurance): Exposure, Ingestion, and Implantation issues and December. 5, 1980 document which can be accessed by clicking the Non-Group Health Plan Recovery link.

HHS is committed to making its websites and documents accessible to the widest possible audience, including individuals with disabilities. We are in the process of retroactively making some documents accessible. If you need assistance accessing an accessible version of this document, please reach out to the guidance@hhs.gov.

DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.

Date Published: 12/31/2020