Every Medicare Eligible Claimant
Attachment D NGHP Data Elements
Non-GHP
Data Elements Input File
Injured Party (The injured party is/was a Beneficiary)
1. Last Name (Mandatory)
2. First Name (Mandatory)
3. Middle Initial (Optional)
4. Address (Mandatory)
5. Telephone (Optional)
6. Email (Optional)
7. Date of Birth (Mandatory)
8. Date of Death (Situational)
9. Gender (Mandatory)
10. Social Security Number (Situational) (Mandatory if HICN not provided, pseudo SSN’s not permitted)
11. Beneficiary HICN (Situational) (Mandatory if SSN not provided Pseudo HICN’s not permitted)
Claimant, if different than Injured Party (Claimant is Medicare Beneficiary’s estate, wrongful death claimant other than estate, survivor action and claimant other than estate)
(All items noted as situational, only needed when claimant not the injured Party)
12. Beneficiary Relationship (Situational) (Estate/Spouse/Child/Sibling or Other)
13. Name and Address (Situational)
14. Telephone and/or Email (Optional)
15. TIN (SSN or EIN) (Situational) (Pseudo SSNs or EINs not permitted)
Primary Plan (Separate Report for Each Plan and/or Insurance Type)
(If settlement for more than two individuals must report separately)
- 16. Insurance Type (Mandatory) (Workers’ Compensation, Liability or No-Fault)
17. Name (Mandatory) (Legal Name)
18. Address (Mandatory)
19. TIN (SSN or EIN) (Mandatory) (Psuedo SSNs or EINs not permitted)
20. Additional Information (Optional)
21. Policy Number (Mandatory)
22. Claim Number (Mandatory) (Internal claim number)
23. No fault Policy Limit (Situational) (In No-Fault)
24. Exhaust Information (Situational) (In No-Fault; Report date only if benefits are fully exhausted)
Attachment D NGHP Data Elements (Continued)
Page 2 of 3
Policy Holder
- 25. Policy Holder Name (Mandatory) (Legal Name)
26. Policy Holder DBA Name (Mandatory) (Mary or may not be the same as legal name)
27. Self-Insured (Mandatory) (Yes or No? Applies to WC and Liability. See supporting document for full explanation of the term “liability self-insurance”.)
Injured Party or Claimant Attorney/Representative
(All items noted as situational applicable when there is an Attorney)
- 28. Attorney Name (Situational)
29. Firm Name (Situational)
30. Attorney Address (Situational)
31. Attorney Phone and/or
Email (Optional)
32. Attorney TIN (SSN or EIN) (Situational) (Pseudo SSNs or EINs not permitted; TIN for individual attorney or firm dependent on which is listed as a payee)
33. State Bar Member
Number and State (Optional)
Incident
- 34. Date of Injury (Mandatory) (For an automobile wreck or other accident, the DOI is the date of the accident. For claims involving exposure, the DOI is the date of first exposure. For claims involving ingestion (for example a recalled drug) it is the date of first ingestion. For claims involving implants, it is the date of the implant (or date of the first implant if there are multiple implants.)
35. Nature of Injury (Situational) (WCIO Nature of Injury Table)
36. Cause of Injury (Situational) (WCIO Cause of Injury Table)
37. State of Venue (Mandatory)
38. ICD-9 Code (up to 5 occurrences) (Situational) (At least 1 ICD-9 Code or Body Part Code)
39. Body Part (up to 5 occurrences) (Situational) (WCIO Body Part Code Table; At least 1 Body Part Code or ICD-9 Code)
40. Product Liability (Mandatory) (Yes or No)
41. Product Liability Information (Situational) If #43 is yes, provide Product generic name, brand name and manufacturer. Also describe alleged harm (free form space provided).
Attachment D NGHP Data Elements (Continued)
Page 3 of 3
Resolution
(All items noted as situational only applicable when a contested claim has been resolved [vs. responsibility accepted without contesting the matter])
- 42. Settlement Date (Situational) (Date of Settlement, Judgment, Award or Other Payment)
43. Amount (Situational) (Amount of Settlement, Judgment or Award)
44. Claim Resolution (Mandatory)
-
- Contested, resolved claim with no on-going responsibility
- Contested, resolved claim with on-going responsibility
- Non-contested claim with on-going responsibility
- Non-contested claim, resolved with no on-going responsibility
45. Funding (Situational) (Was funding of the settlement, judgments, award or other payment contingent upon proof of resolution of Medicare’s fee for service Medicare Secondary Payer recovery claim? Yes or No.)
Definitions
CMS – Centers for Medicare & Medicaid Services
COBC – Coordination of Benefits Contractor
MSPRC – Medicare Secondary Payer Recovery Contractor – Chickasaw Nation Industries, Inc. Administration Services, LLC (CNI)
Future Medical Payments & Medicare Set-Asides
It is well established that Medicare’s interest must be considered anytime a Medicare beneficiary recovers for future medicals. CMS expects funds allocated to medical on Medicare covered services be exhausted before Medicare is ever billed. The Social Security Act precludes Medicare payment for services to the extent that payment has been made or can be reasonably expected to be made promptly under liability insurance. In this context, a Medicare Set-Aside should be considered.
MMSEA 111 PRA NGHP Data Elements 843008.doc
