New Option for Terminating ORM

Recently, CMS issued an updated Section 111 User Guide. One of the changes noted was an additional option for when an RRE may report ORM termination. Section 6.3.2 of the User Guide provides as follows, with the additional language being italicized:

"When ORM ends, the RRE should report the date that ORM terminated and should NOT delete the record. Please note that a TPOC amount is not required to report an ORM termination date.

An ORM termination date should not be submitted as long as the ORM is subject to reopening or otherwise subject to an additional request for payment. An ORM termination date should only be submitted if one of the following criteria has been met:

• Where there is no practical likelihood of associated future medical treatment, an RRE may submit a termination date for ORM if it maintains a statement (hard copy or electronic) signed by the beneficiary’s treating physician that no additional medical items and/or services associated with the claimed injuries will be required;

• Where there is no practical likelihood of associated future medical treatment, which is reflected by meeting ALL of the following:

  • No claims were paid with any diagnoses codes related to alleged ingestion, implantation, or exposure; and

  • No claims were paid, for any medical item or service related to the case, within five (5) years of the date of service of any such claim; and

  • Treatment did not include, nor were any claims paid related to, a medical implantation or prosthetic device; and

  • The total amount paid by the insurer, for all medical claims related to the case, did not exceed $25,000.

Note: If, at any time, any of the parameters set forth above should no longer be applicable, the insurer must then update the ORM record to reflect that they, once again, have ongoing responsibility for medicals (i.e., update the termination date to all zeroes). Should the case once again fall under these parameters (for example, if five years elapse from the last relevant date of service), then ORM for that case may once again be terminated in accordance with the criteria above.

• Where the insurer’s responsibility for ORM has been terminated under applicable state law associated with the insurance contract;

• Where the insurer’s responsibility for ORM has been terminated per the terms of the pertinent insurance contract, such as maximum coverage benefits."

If you have any questions about this new option for terminating ORM, please let us know and we will be happy to answer them.