Mandatory Insurer Reporting (NGHP)

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Reporting is accomplished by either the submission of an electronic file of liability, no-fault, and workers’ compensation claim information, where the injured party is a Medicare beneficiary, or by entry of this claim information directly into a secure Web portal, depending on the volume of data to be submitted. Upon receipt of this information, CMS checks whether the injured party associated with the claim report is a Medicare beneficiary, and determines if the other insurance is primary to Medicare. CMS then uses this information in the Medicare claims payment process and, if Medicare paid first when it should not have, uses it to seek repayment from the other insurer or the Medicare beneficiary.

Mandatory Insurer Reporting for Group Health Plans (GHP)

The purpose of Section 111 reporting is to enable Medicare to correctly pay for the health insurance benefits of Medicare beneficiaries by determining primary versus secondary payer responsibility. Section 111 authorizes CMS and GHP RREs to electronically exchange health insurance benefit entitlement information. On a quarterly basis, an RRE must submit a file of information about employees and dependents who are Medicare beneficiaries with employer GHP coverage that may be primary to Medicare. In exchange, CMS provides the RRE with Medicare entitlement and enrollment information for those individuals in the GHP that can be identified as Medicare beneficiaries. This mutual data exchange helps to ensure that claims will be paid by the appropriate organization at first billing. The Section 111 GHP reporting process also includes an option to exchange prescription drug coverage information to coordinate benefits related to Medicare Part D.
Source: the official U.S. government site for Medicare

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