Data Elements Insurers Should Report to CMS

The defense will be required to complete all of the data points unless indicated. The data points the plaintiff’s counsel will need to provide to the defense are in bold type.  For simplicity, we have combined all ICD-9 code requirements into one line item for this exhibit; and have eliminated optional fields and the fields reserved for future use.

(The full list of data points can be found in the MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers’ Compensation User Guide Version 1.0 dated March 16, 2009 at Appendix A - D.  An electronic version of this User Guide may be found by clicking here.)  

Claim Input File Header

1 Record Identifier
2 Section 111 Reporter ID
3 Section 111 Reporting File Type
4 File Submission Date

Claim Input Detail Record

Injured Party/Medicare Beneficiary Information
1 Record Identifier
2 Document Control Number (“DCN”)
3 Action Type
4 Injured Party HICN (Required if SSN not provided)
5 Injured Party SSN (Required if HICN no provided)
6 Injured Party Last Name
7 Injured Party First Name
9 Injured Party Gender
10 Injured Party Date of Birth

Injury/Incident/Illness Information
12 CMS Date of Incident
15 Alleged Cause of Injury, Incident or Illness  (Required after 1/1/11)
17 State of Venue
19 - 55 ICD-9 Diagnosis Code 1 – Code 19
57 Description of Illness/Injury (Required through 12/31/10 if #15 or #19 not completed)
58 Product Liability Indicator
59 Product Generic Name  (Required if mass tort)
60 Product Brand Name   (Required if mass tort)
61 Product Manufacturer    (Required if mass tort)
62 Product Alleged Harm    (Required if mass tort)

Self Insurance Information
64 Self Insured Indicator  (Required if WC or Liability)
65 Self Insured Type  (Required if self-insured)
66 Policyholder Last Name (Required if #65 is an individual)
67 Policyholder First Name   (Required if #65 is an individual)
68 DBA Name  (Required if #65 is an organization and #69 not provided)
69 Legal Name  (Required if #65 is an organization and #69 not provided)

Plan Information
71 Plan Insurance Type
72 Tax ID Number (“TIN”)
74 Policy Number
75 Claim Number
81 No-Fault Insurance Limit (Required if #71 is no fault)
82 Exhaust Date for Dollar Limit for No-Fault Insurance (Required if #71 is no-fault and limit is reached/exhausted)
83 Reserved for Future Use

Injured Party’s Attorney or Other Representative Information (#84 - #95 required if injured party is represented)
84 Injured Party Representative Indicator
85 Representative Last Name
86 Representative First Name
87 Representative Firm Name
88 Representative TIN
89 Representative Mailing Address Line 1
91 Representative City
92 Representative State
93 Representative Mail Zip Code
95 Representative Phone

Settlement, Judgment, Award or Other Payment Information
98 Ongoing Responsibility for Medicals (“ORM”) Indicator
99 ORM Termination Date
100 Total Payment Obligation to the Claimant (“TPOC”) Date (May be required)
101 TPOC Amount
102 Funding Delayed Beyond TPOC Start Date

Claimant Information 1 ( #104 - #116 required if claimant is not the injured party)
104 Claimant 1 Relationship
105 Claimant 1 TIN
106 Claimant 1 Last Name
107 Claimant 1 First Name
108 Claimant 1 Middle Initial
109 Claimant 1 Mailing Address Line 1
110 Claimant 1 Mailing Address Line 2
111 Claimant 1 City
112 Claimant 1 State
113 Claimant 1 Zip
114 Claimant 1 Zip + 4
115 Claimant 1 Phone
116 Claimant 1 Phone Extension

Claimant 1 Attorney/Other Representative Information (Required if claimant, who is not the injured party, has representation)
118 Claimant 1 Representative Indicator
119 Claimant 1 Representative Last Name
120 Claimant 1 Representative First Name
121 Claimant 1 Representative Firm Name
122 Claimant 1 Representative TIN
123 Claimant 1 Representative Mail Address Line 1
125 Claimant 1 Representative Mailing City
126 Claimant 1 Representative State
127 Claimant 1 Representative Zip
129 Claimant 1 Representative Phone

Claim File Auxiliary Record – Additional fields required if there are additional claimants to report for the associated Detail Claim Record

Claim Input File Trailer Record

1 Record Identifier
2 Section 111 Reporter ID
3 Section 111 Reporting File Type
4 File Submission Date
5 File Record Count

TIN Reference Header Record

1 Record Identifier
2 Section 111 Reporter ID
3 Section 111 Reporting File Type
4 File Submission Date

TIN Reference Detail Record

1 Record Identifier
2 Section 111 Reporter ID
3 TIN
4 Office Code/Site ID
5 TIN/Office Code Mailing Name
6 TIN/Office Code Mailing Address Line 1
8 TIN/Office Code City
9 TIN/Office Code State
10 TIN/Office Code Zip

TIN Reference Trailer Record

1 Record Identifier
2 Section 111 Reporter ID
3 Section 111 Reporting File Type
4 File Submission Date
5 File Record Count

 

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