1. Next Steps for Lloyd’s Market GL-Service Users
CMS Section 111 Reporting

2. Moving Forward
The purpose of this guide is to assist Lloyd’s Market GL-Service Users with direction regarding processes for CMS Section 111 Reporting once the Injured Party’s Medicare Eligibility status has been determined.
This guide assumes the following:
Users have attended the Mandatory Insurer Reporting Introductory Webinar for the Lloyd’s Market
Users have attended the Implementation Detail Webinar for the Lloyd’s Market
The Managing Agent, Coverholder, TPA or Attorney organisations (AKA Data Source) are in a Production Status with Gould & Lamb and were provided with GL-Service credentials if applicable
Minimum requiring Eligibility data has been provided

3. Review: Process Flow
Two Processes; Monthly Query (Eligibility Check) and Quarterly Claim Input (Reporting).
Data Sources submit ‘Big 5’ data elements to MIRService via an Input file or GL-Service Direct Data Entry.
Each month, MIRService creates a Medicare Query Input file and submits to CMS.
Lloyds Market RREs are Submission Group 3 and queries will be processed on the 8th of every month
Within 14 days, CMS provides a Medicare Query Response file.
MIRService provides Eligibility results to the Data Source via a weekly Claim Status response file and/or in GL-Service.
Claims involving Medicare Eligible injured parties require additional data for the Quarterly Claim Input file to CMS via input file or GL-Service
Per each RRE’s assigned quarterly reporting group date, MIRService submits the RRE’s Claim Input file to CMS.
Lloyds Market RREs are Submission Group 3 and quarterly files will be processed on 1/15, 4/15, 7/15. and 10/15
Within 45 days, CMS provides a Claim Response file, advising as to CMS’ disposition of each claim record.
MIRService provides CMS Responses to the Data Source via a quarterly Claim Response file.
Data Sources submit update and new claim information on a regular basis via input file and/or GL-Service.

4. Determining Eligibility Status
Generally, The Medicare Query is submitted to CMS for Lloyd’s RREs the 8th of each month and a Query Response file is received the 22nd of each month.
Eligibility results may be found in GL-Service and in the weekly Claims Status (scheduled) response file from Gould & Lamb.

5. Eligibility Status in GL-Service
Client Administrators and users with an ‘Update-All’ view may review Medicare Eligible claims by ensuring the predefined query (1) is set to ‘Only Medicare Eligible or filtering the default column ‘Eligible’ (2) to ‘Yes’.
Should “No data to display” be returned or values of blank or Undetermined be returned in the Eligible column, the Injured Party is either not Medicare Eligible or the Injured Party’s Big 5 data should be reviewed for accuracy.
Only the Injured Party’s legal name, as it appears on their Social Security Card or Medicare Care should be provided. 1 2

6. Eligibility Status, Response File
A GL Claim Status file is provided weekly. It contains claim validation, eligibility, and Compliance Alerts for all claims currently in MIRService for the customer.
Naming Format: {G&L Customer #}_{Sequence #}_{Created Date & Time}_scheduled.{Extension}
The Claim Status file is provided in tab delimited text format, which may be imported into Excel or other ancillary systems.
It contains a field providing the results of the monthly Medicare eligibility check.
A blank value indicates Medicare eligibility has not yet been confirmed for this claim’s injured party based on the submitted data.
A value of “U” (undetermined) indicates that Medicare could not find a match for the injured party, based on the information provided.
A value of “Y” (yes) indicates Medicare was able to match the injured party information with a known Medicare eligible individual.

7. Review: Triggering Events for Reporting
For claims involving Medicare eligible injured parties:
Acceptance of Ongoing Responsibility for Medical (ORM) post 1 January 2010
Termination of ORM
Total Payment Obligation to the Claimant (TPOC)
Post 1 October 2011 for Liability claims

8. Additional Data for Medicare Eligible Claims
General: this section deals with situations involving Workers’ Compensation, General Liability and No-Fault Auto claims.
No-Fault Auto: this section deals with situations involving only No-Fault Auto claims.
Additional Data Fields for use with multiple claimants: Claimant 1-4 Instructions

9. General Claim Data Required Optional Claim Number CMS DOI
Enter the claim number assigned to the claim in your claims administration system
CMS DOI
For accidents, use the actual date of the accident; for occupational disease or exposure use the date of first exposure. Initially this field will be populated with the Date of Accident and should be changed to the Date of First Exposure by the adjuster handling the claim.
State of Venue
Select the state in which the accident occurred or from where it is being adjudicated.
Optional
Industry DOI
Traumatic injury or accidents use the actual date of the accident; for occupational disease or exposure use the date of last exposure

10. General Claim Data Situational; Injured Party Rep
Injured Party Rep Indicator
Code indicating the type of attorney/other representative information provided.
Last Name
Required if the Injured Party has a representative; embedded hyphens (dashes), apostrophes and spaces are acceptable.
First Name
Required if the Injured Party has a representative; may only contain letters and spaces.
Firm Name
Either Representative Last Name and First Name - or - Representative Firm Name is required if Injured Party has a representative.
TIN
Should be provided if the Injured Party has a representative and the TIN or EIN is available.

11. General Claim Data Situational; Injured Party Rep Mail Address 1
Required if Injured Party has a representative. Street number and street name should be placed on the Address Line 1 field.
Mail Address 2 - Optional
City
Required if Injured Party has a representative. Mailing address city for the representative named above.
State
Required if Injured Party has a representative. US Postal abbreviation state code for the representative named above.
Zip
Required if Injured Party has a representative. 5-digit zip code for the representative named above.
Zip +4 - Optional
Phone
Required if Injured Party has a representative. Telephone number of the representative named above.
Phone Ext. - Optional

12. General Claim Data Required; ICD-9 Codes Optional
You must provide a valid ICD-9 Alleged Cause of Injury Code. Click on the ellipses box next to the field for a listing of current accepted ICD-9 “E Codes”.
You must provide a minimum of one valid ICD-9 Diagnosis Code. Click on the ellipses box next to the field for a listing of current accepted ICD-9 Diagnosis Codes.
Optional
ICD-9 Diagnosis Codes 2 – 19; Required when multiple body parts are affected.

13. General Claim Data Required; Plan Data Policy Number
The unique identifier for the policy under which the underlying claim was filed.   If liability self‐insurance or workers’ compensation self‐insurance, fill with 0’s if  you do not have or maintain a specific number reference.
Plan Insurance Type
Select from: D = No‐Fault, E = Workers’ Compensation, L = Liability  
Plan Contact Dept Name
Name of department for the Plan Contact to which claim-related communication and correspondence  should be sent.
Plan Contact Last Name
Plan Contact First Name
Last Name and First Name of individual  that should be contacted at the Plan for  claim‐related communication and  correspondence.
Plan Contact Phone
Plan Contact

14. General Claim Data Required; TIN Information TIN State
Where Lloyd’s RREs do not have an IRS-assigned Tax ID Number, a pseudo-TIN in the format of 9999xxxxx was created
State
Where the Lloyd’s RRE is considered a foreign entity and no US address is available, supply “Outside US (FC)“.
Foreign Address 1 thru 4
First thru fourth line of a non-US mailing address.

15. Auto / No Fault Data Required; if No Fault Insurance Limit
Dollar amount of limit on no‐fault insurance. Specify dollars and cents. Fill with all 9’s if there is no dollar limit.
Exhaust Date for $ Limit
Date  on  which  limit was  reached  or  benefits  exhausted  for   No‐Fault  Insurance  Limit.   

16. General Claim Data Required; MSP Compliance
Total Proposed Settlement Amount
Dollar  amount  of the expected  settlement/judgment/award,   including  indemnity,  attorney  fees,   unresolved  conditional  payments  and  future  medicals  (allocation).
Complete  only  when  Claims  Status   moves  to  “Positioned  for  Settlement”. Select  from: Yes/No
Claim Status
Select from: Open (O): The case is open and not yet  ready to settle, Positioned for Settlement (P): Settlement is imminent, Settled (S): Case has been closed by  settlement/judgment/award, Closed (C): Case has been closed by  statute of limitations or policy limit 
Closing future Medical
Is  part  of  the  Settlement  Closing / Limiting  Future  Medical?  
Complete  only  when  Claims  Status   moves  to  “Positioned  for  Settlement”. Select  from: Yes/No  

17. General Claim Data Required: ORM ORM Indicator ORM Termination Date
Indication of whether the RRE has on‐going responsibility  for medicals (ORM).
Select from: Yes/No 
If ORM is established, then it never gets reverted to No.
ORM Termination Date
Date on‐going responsibility  for medicals ended, where  applicable.
Only applies to claims submitted with ORM Indicator = Y 
ORM Termination Date is not applicable if claimant retains  the ability to submit/apply for  payment for additional  medicals related to the claim.

18. General Claim Data
Situational; TPOC, required when there has been a settlement, judgment or award.
TPOC 1 Date
Date of the later of the signed written agreement or court approval if required.
TPOC 1 Amount
Dollar amount of the TPOC. If there is a structured settlement, the amount is the total payout amount.   If a settlement provides for the purchase of an annuity, it is the total payout from the annuity.
TPOC 1 Funding Delayed Beyond Date
If  funding  for  the  Total  Payment  Obligation  to  Claimant  Amount  1  is   delayed,  provide  actual  or  estimated   date  of  funding.
Repeat the above for TPOC fields 2  through 5 if there are multiple  settlement / judgment / award payments provided to the  claimant.

19. Additional Data Fields – Multiple Claimants
Situational; Required when the injured party is deceased and another individual or group is the claimant.
Relationship
Relationship of the claimant to the injured party/Medicare beneficiary. This field also indicates whether the claimant name refers to an individual or an entity/organization (e.g. “The Trust of John Doe” or “The Estate of John Doe”).
Valid values:
E = Estate, Individual Name Provided
F = Family Member, Individual Name Provided
O = Other, Individual Name Provided
X = Estate, Entity Name Provided (e.g. "The Estate of John Doe")
Y = Family, Entity Name Provided (e.g. "The Family of John Doe")
Z = Other, Entity Name Provided (e.g. "The Trust of John Doe")
Space = Not applicable (rest of the section will be ignored)
Required if injured party is deceased and claimant is not the injured party.

20. Additional Data Fields – Multiple Claimants
Situational; Claimant 1
Last Name
Embedded hyphens (dashes), apostrophes and spaces accepted.
Required if injured party is deceased and claimant is not the injured party and Claimant 1 Relationship is 'E', 'F' or 'O'.
First Name
May only contain letters and spaces.
Middle Initial – Optional
Entity/Organization Name
Required if injured party is deceased and claimant is not the injured party and Claimant 1 Relationship is ‘X', ‘Y' or ‘Z'.

21. Additional Data Fields – Multiple Claimants
Situational; Claimant 1
Address 1
Street number and street name should be placed on one address line field while other information such as suite number, attention to, etc. should be placed on the other.
If no US address is available, fill with spaces and supply 'FC' in the corresponding State Code.
Required if injured party is deceased and claimant is not the injured party
Address 2 – Optional
City
Mailing address city for Claimant 1. If no US address is available, fill with spaces and supply 'FC' in the corresponding State Code.
State
US Postal abbreviation State Code for the claimant named above.
If no US address is available, supply 'FC'.
Zip
5-digit Zip Code for Claimant 1.
If no US address is available, fill with zeroes and supply 'FC' in the corresponding State Code.
Required if injured party is deceased claimant is not the injured party
Zip + 4 – Optional

22. Additional Data Fields – Multiple Claimants
Situational; Claimant 1
TIN
Federal Tax Identification Number (TIN), Employer Identification Number (EIN) or Social Security Number (SSN) of Claimant 1.
Must not match other claimant(s) listed on the Customer Claim Input Record.
Required if injured party is deceased and claimant is not the injured party.
Phone
Telephone number of the claimant named above. Format with 3-digit area code followed by 7-digit phone number with no dashes or other punctuation
If no US phone number is available, fill with zeroes and supply 'FC' in the corresponding State Code.
Required if injured party is deceased and claimant is not the injured party
Phone Ext. - Optional

23. Additional Data Fields – Multiple Claimants
Situational; Claimant 1 Rep
Injured Party Rep Indicator
Code  indicating  the  type  of  attorney/other  representative  information  provided.
Last Name
Required if Claimant 1 has a representative; embedded hyphens (dashes), apostrophes and spaces are acceptable.
First Name
Required if Claimant 1 has a representative; may only contain letters and spaces.
Firm Name
Either Representative Last Name and First Name - or - Representative Firm Name is required if Injured Party has a representative.
TIN/EIN/SSN
Should be provided if Claimant 1 has a representative and the TIN, EIN or SSN is available.

24. Additional Data Fields – Multiple Claimants
Situational; Claimant 1 Rep
Mail Address 1
Required if Injured Party has a representative. Street number and street name should be placed on the Address Line 1 field.
If no US address is available, fill with spaces and supply 'FC'. in the corresponding State Code.
Mail Address 2 - Optional
City
Required if Claimant 1 has a representative. Mailing address city for the representative named above.
State
Required if Claimant 1 has a representative. US Postal abbreviation state code for the representative named above.

25. Additional Data Fields – Multiple Claimants
Situational; Claimant 1 Rep
Zip
Required if Claimant 1 has a representative. 5-digit zip code for the representative named above.
If no US address is available, fill with spaces and supply 'FC'. in the corresponding State Code.
Zip +4 - Optional
Phone
Required if Claimant 1 has a representative. Telephone number of the representative named above.
Phone Ext. - Optional
Repeat these fields on Claimant 2  through 4 tabs, if applicable.

26. Data Validations
Indicates edit, back-fill or corrections which should be made.
Real-time validations in GL-Service,
Point-in-time validations in weekly Claim Status File.

27. Data Validation
Data validation rules are applied to Claim Records in GL-Service in two scenarios
Upon Claim Update (1)
Ad-hoc Request (2) 1 2

28. Data Validations Data Validation Warning Message Example:
Format: Error Code, Field Name, Description

29. Data Validation
Data Validation Statuses and Descriptions are found in the weekly Claim Status File.
The Claim Status File is provided in tab delimited text format, which can be viewed in Excel.
Validation Status of “Successful” indicates the record is currently complete based on G&L’s analysis.
Validation Status of “Warning” indicates the record has deficiencies requiring correction.

30. Data Validation
Detailed information regarding Validations can be found in the High Level Errors spreadsheet, located in the Customer Document Library.
Customer Document Library:

31. Identifying Reportable Claims
Triggering event(s) have occurred on a claim record involving a Medicare Eligible Injured Party (See Review, slide 7).
Claim Record exceeds TPOC Interim Reporting Thresholds.

32. Identifying Reportable Claims in GL-Service
Client Administrators and users with an ‘All’ view may review MIR Reportable claims by ensuring the predefined query (1) is set to ‘Only MIR Reportable’ or customizing the GL-Service Layout by adding the field ‘ORM/TPOC Reportable and filtering the column with a value of ‘Yes’ (2).
Users with an assigned view of ‘Discrete’ may customize the GL-Service Layout adding the field ‘ORM/TPOC Reportable and filtering the column with a value of ‘Yes’ (2). 1 2

33. Identifying Reportable Claims, Response File
The weekly Claim Status File provides a “MIR Reportable” field which contains a Yes/No value, indicating those claims which meet criteria for the quarterly Claim Input file to CMS.
This file also provides the date the claim record was last reported to CMS for the quarterly report.
The Claim Status File is provided in tab delimited text format which can be imported into Excel.
IMPORTANT NOTE: Whether identified in GL-Service or in the weekly Claim Status File, reportable records which have Validation Descriptions / Errors must be corrected as soon as possible. Records will be reported to CMS regardless of existing errors, likely to be rejected by CMS. These errors may cause CMS ‘Threshold Errors’ either delaying or stopping the processing of the RREs entire Claim Input file. This delay or cessation of processing may result in reporting penalties of $1,000 / claim / day (approximately £622 / claim / day).

34. Quarterly Claim Response from CMS
Generally, Gould & Lamb submits the quarterly Claim Input file for Lloyd Syndicate’s RREs on the 15th of the first month of each quarter (January 15, April 15, July 15, October 15).
CMS provides a Claim Response file, advising as to the disposition of each claim record, within 45 days of submission of this Claim Input file.
The claim response data is available on the Responses tab in GL-Service as well in the Claim Response file.

35. Reviewing Claim Responses in GL-Service
Quarterly Claim Responses may be found in GL-Service on the ‘Responses’ tab.
On the search line, select the ‘Received’ period (1) [Anytime, This Year, Previous Quarter, Previous Month, This Quarter, This Month].
Review the ‘Disposition’ status of each record meeting the search criteria (2) [Accepted, Rejected, Ineligible, In Process].
‘Created On’ date (3) is the date the Claim Response file for selected records had been received from CMS. 1 2 3

36. Reviewing Claim Responses in GL-Service
When ‘Disposition’ indicates the record has been Rejected, review the reason for rejection by clicking on the Error codes (1). GL-Service will display the error code, field and error description associated with the error.
Should ‘Disposition’ indicate the record is ‘Accepted’, review for possible Compliance Flags (2) to determine if a non-fatal error occurred which requires correction or determination that the claim had been reported late.
A ‘Disposition’ of ‘In Process’ will be automatically resubmitted the following quarter (should the record still meet reporting criteria).
An ‘Ineligible’ response indicates that the Injured Party is not currently Medicare Eligible. Gould & Lamb will continue to submit these records for the monthly Query.
The ‘Detail’ link in the ‘Actions’ column (3) will provide a full view of CMS applied data, each of the 10 possible rejection error codes and compliance flags 3 1 2

37. Reviewing Claim Response, Claim Response file
Claim Responses from CMS are provided to the customer in a ‘Claim Response’ file from Gould & Lamb
Generally, the naming convention for this response file is:
{G&L Customer #}_{RRE Id}_{Sequence #}_{Submitted Date & Time}_output.txt
The format of this file is fixed width flat file (1).
The response file maybe reviewed in a text editor such as Notepad++ or Text Pad. 1

38. Reviewing Claim Response, Claim Response file
The Claim Response file maybe imported into Excel as fixed width (2).
The End Position of each field will be needed to set column breaks. You may obtain this information from the G&L MIR File Specification which may be downloaded from the Customer Document Library:
The Claim Response file specification will also be needed for addition of column headers for your Excel spreadsheet.
Review the Applied Disposition Code and any Applied Error Code(s) or Compliance Flag(s) for each record. 2

39. MSP Compliance
Medicare Secondary Payer Compliance alerts are provided on each record based on values provided in the MSP Compliance fields
(See Slide 16).
Alerts are also provided on the weekly Claim Status response file.
Plan Contacts will receive notifications seeking approval of services for CPR (Conditional Payment Research).
Gould & Lamb is the preferred vendor for all MSP Services for the Lloyd’s Market.

40. MSP Compliance in GL-Service
Click on the Claims tab. Select Layout and Customize Columns.
Select the field ‘Compliance Alert’ (1), drag and drop into your view.
Review record responses in the Compliance Alert fields for recommended services such as CPR Needed, CPR/MSA/CSA Needed, etc.
A value of ‘Unknown’ indicates that the MSP Compliance fields have not been completed for the record in GL-Service. 1 2

41. MSP Compliance
Claims where Conditional Payment has been identified should not be settled until the lien value has been negotiated.
Referral forms maybe found on Gould & Lamb’s home page:
Questions or status updates regarding MSP and/or recommended services maybe addressed to:
Rachel Melanson
Corporate Account Manager
Tel Ext. 1451
Cell

42. Key Contacts Scott Huber, Vice President of Information Services
Tel Ext. 1456
Kip Daniels, Executive Vice President of Strategic Services
Tel Ext. 1077
Rachel Melanson, Corporate Account Manager,
Tel Ext. 1451
Cell
John Miano, Reporting Services Manager
Tel Ext. 1518
Cell
Michael Battles, Implementation Manager
Tel Ext. 1522
Cell
Elizabeth ‘Buffy’ Brewington, Implementation Manager
Tel Ext. 1512
Cell

43. Important Email and Websites
Gould & Lamb Support of the Lloyd’s Market:
Tel Ext. 1133
Gould & Lamb Home Page: