An Administratively Closed Claim Does Not Equal ORM Termination
Heather Sanderson
February 15, 2016

In reviewing numerous reporting programs we have found that there is confusion within the industry regarding the proper indicators in which an RRE can terminate Ongoing Responsibility for Medical (ORM) for Section 111 MMSEA reporting. ORM occurs where an RRE has undertaken the legal responsibility to pay for a claimant’s medical treatment or where an RRE is required to pay for a claimant’s medical treatment under state law. ORM can last indefinitely until the RRE is able to terminate legal responsibility to pay for ongoing medical treatment. As CMS guidance has been relatively clear and has set out three main categories in which ORM termination can occur, RREs should familiarize themselves with the CMS guidance on this issue.

As a background, the three main categories in which an RRE can populate an ORM termination date are the following:

1. The medical benefits available to the claimant have exhausted under state law;

2. A doctor has provided a letter that future medical treatment related to the case is not likely to occur; or

3. The case has settled and the carrier has terminated its responsibility to fund future medical as part of that agreement.

The administrative closure of a file on the insurance carrier’s part does not warrant an ORM termination under CMS’ guidelines. While CMS understands a carrier’s desire to terminate ORM at the time of administrative closure, it has taken the position that if the claimant has a right to reopen or petition to re-open the medical portion of the claim at any point in the future, ORM remains open.

Medicare uses Section 111 MMSEA data to coordinate Medicare benefits. Under the MSP, Medicare cannot pay if another plan has paid or is reasonably likely to pay. Medicare suspends benefits because the ORM data tells CMS that the RRE is responsible for current related treatment.

When the RRE tells Medicare that ORM has terminated, CMS’ expectation is that it is for one of the three states reasons above. Any ORM termination date that does not coincide with Medicare’s rules subject the RRE to potential exposures beyond penalties. We urge all RREs to manage ORM termination dates with care due to this potential exposures.

For official CMS guidance on ORM, please see the following:

NGHP User Guide Version 4.9 (December 14, 2015)- See Section 6.3. This section can be found here.

CMS ORM Presentation- The Presentation can be found here.

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Heather Schwartz Sanderson, Esq., MSCC, CHPE, CLMP, CMSP

Chief Legal Officer

Franco Signor LLC