MMSEA Alert: TPOC Dollar Thresholds for Worker’s Compensation

Workers Compensation Lien ResolutionThe Centers for Medicare and Medicaid Services (“CMS”) issued two alerts on June 20, 2012 related to threshold requirements for reporting of Workers’ Compensation claims.   The following will address each alert separately.

Mandatory Total Payment Obligation to the Claimant (“TPOC”) Dollar Thresholds for Workers’ Compensation

CMS has revised the mandatory TPOC thresholds for workers’ compensation claims.  This alert amends the current guidance in Section 11.4 of Version 3.3 of the User Guide. The chart below lays out the new thresholds and timetable for workers’ compensation TPOCs:

Total TPOC Amount related to a Workers’ Compensation claim TPOC Date on or After Section 111 Reporting Required in the Quarter Beginning
TPOCs over $5,000 October 1, 2010 January 1, 2011
TPOCs over $2,000 October 1, 2013 January 1, 2014
TPOCs over $300 October 1, 2014 January 1, 2015

Click here to view this alert on the CMS website.


Mandatory Minimum Dollar Threshold for Workers’ Compensation Ongoing Responsibility for Medicare (“ORM”) Extended Indefinitely

Version 3.3 of the User Guide provides for an exclusion from MMSEA reporting if certain criteria are met for workers’ compensation cases where the responsible reporting entity has accepted responsibility for on-going medicals.  This exclusion was scheduled to expire as of December 31, 2012.  CMS has not changed the criteria, but per this alert is indefinitely extending the exclusion from reporting if the following criteria are met:

  • The claim is for “medical only”; and
  • The associate “lost time” is no more than the number of days permitted by the applicable workers’ compensation law for “medicals only” (or 7 calendar days if applicable law has no such limit); and
  • All payment(s) has/have been made directly to the medical provider; and
  • Total payment for medicals does not exceed $750.

Click here to view this alert on the CMS website.

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