CMS Issues Updated User Guide, Provides New Guidance for TPOCs with Delayed Funding


CMS recently issued an updated User Guide clarifying the use of the Funding Delayed Beyond TPOC Start Date field. In an Alert in November 2021, CMS had issued guidance addressing the use of this field that appeared to be inconsistent with previous guidance. The new User Guide clarifies the Alert and provides that TPOC is reportable once the criteria below are met.

  • The alleged injured/harmed individual to or on whose behalf payment will be made has been identified.

  • The TPOC amount (the amount of the settlement, judgement, award, or other payment) for that individual has been determined.

  • The TPOC amount (the amount of the settlement, judgement, award, or other payment) for that individual has been determined.

The previous version of the User Guide provided that TPOC is reportable when “the alleged injured/harmed individual to or on whose behalf payment will be made has been identified” and “the TPOC Amount for that individual has been identified.” The provision that “the RRE knows when the TPOC will be funded or disbursed to the individual or their representative(s)” is a new criterion for determining when TPOC is reportable. Additionally, the new User Guide includes a new requirement that RREs must list the TPOC funding date in the Funding Delayed Beyond TPOC State Date field when the funding date is more than 30 days after the TPOC date. The User Guide provides as follows:


RREs should retain documentation establishing when these criteria were or will be met. RREs should not report the TPOC until the RRE establishes when the TPOC will be funded or disbursed. In some situations, funding or disbursement of the TPOC may not occur until well after the TPOC Date. RREs may submit the date the TPOC will be funded or disbursed in the corresponding Funding Delayed Beyond TPOC Start Date field when they report the TPOC Date and TPOC Amount, but must do so if the TPOC Date and date of the funding of the TPOC are 30 days or more apart.


Timeliness of MMSEA Section 111 reporting for a particular Medicare beneficiary will be based upon the latter of the TPOC Date and the Funding Delayed Beyond TPOC Start Date.


As indicated above, the new requirements for reporting TPOC will apply when the TPOC funding date is more than 30 days after the TPOC date. The application of the new requirements will help avoid CMS seeking recovery in situations when a settlement agreement has been signed but funds have not been disbursed yet.


The new User Guide also incorporates guidance from a November 2021 Alert on reporting policy limits correctly for no-fault claims. The new User Guide provides the guidance below.


In some states, depending on various factors associated with the incident being reported, no-fault policy limits may vary. The reported Policy Limit should reflect the amount the RRE has accepted responsibility for at the time the record is submitted or updated. Just as importantly, if the Section 111 record needs to be corrected to reflect a new Policy Limit, the RRE should update the record as soon as possible.


The November Alert on reporting policy limits correctly stated that “we advise the RRE to consider contacting their EDI Representative to submit an off-cycle Section 111 report with new policy limit information, rather than wait for their next Section 111 reporting cycle.” RREs are able to submit off-cycle reports, but RREs are limited to one file submission every 14 days and a subsequent file submission will not be processed until the prior file is processed and a response file is available. Normally response files are issued in less than a week, but it is possible for response files to be delayed.


In accordance with the implementation of the PAID Act, the new User Guide reflects that the query response file has been updated to include the Contract Number, Contract Name, Plan Number, Coordination of Benefits (COB) Address, and Entitlement Dates for the last three years (up to 12 instances) of Medicare Advantage Plan and Medicare Prescription Drug Plan enrollment. There are certain situations in which plan enrollment may change more than once during a calendar year, such as when a beneficiary moves outside a plan’s service area.


The User Guide also reflects that the $750.00 TPOC reporting threshold was extended for 2022, as we recently reported. As such, physical trauma-based liability insurance TPOCs of $750.00 or less are not reportable to CMS. In addition, no-fault and workers’ compensation TPOCs of $750.00 or less are not reportable when the RRE does not otherwise have ongoing responsibility for medicals.


Finally, the User Guide was updated to reflect that the ICD-10 code G71.20 (congenital myopathy, unspecified), which was added to the ICD-10-CM effective October 1, 2021, has been removed from the list of excluded ICD-10 codes for no-fault insurance.


Please let us know if you have any questions about the new User Guide or other Section 111 reporting issues. We will be glad to help.


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