Medicare Delivers: PAID Act File Specifications and Expanded ORM Termination Parameters

PAID Act

Medicare released an updated Non-Group Health Plan (NGHP) User Guide today announcing technical changes to the Query Response File to allow for the exchange of Medicare Advantage Plan data as well as Part A and B enrollment date data in the query file. This will go into effect December 11, 2021. The Query Response File will be updated to include: Contract Number, Contract Name, Plan Number, Coordination of Benefits (COB) Address, and Entitlement Dates for the last three years (up to 12 instances) of Part C and Part D coverage. The updates will also include the most recent Part A and Part B entitlement dates. The HIPAA Eligibility Wrapper Software (HEW) software will also be modified to extract the additional fields from the response file. Testing is slated to occur this fall.

Reminder: Medicare will host a PAID Act webinar on June 23^rd at 1 PM ET.

ORM Termination

Medicare also released Ongoing Responsibility for Medical (ORM) Termination guidance effective immediately. ORM may now also be terminated if ALL of the following are true:

• 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.

“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.”

These are significant and very useful developments! Our Mandatory Insurer Reporting team is unpacking the technical updates and ECS is ready to swiftly implement and incorporate the changes in our MIR Service Section 111 reporting and conditional payment services. Stay tuned for more. If you have question about the PAID Act / ORM Termination changes, you would like assistance interpreting and implementing these changes, or you’d like assistance with a mass ORM termination project, please reach out to Annie at 651-262-9618 or Annie.Davidson@ExamWorksCompliance.com. You may also contact MIRService.Support@ExamWorksCompliance.com.