Field

Description

ORM Indicator

Select Yes if there is ongoing responsibility for the medical costs associated with this claim or No if the responsibility has ended or the claimant retains the ability to submit/apply for payment for additional medicals related to the claim. Once the claim is accepted, this field will be read-only. The Yes value will remain in the field even when a subsequent update record is being submitted to report the termination date if the record was first submitted with ORM = Yes.

New Claims: If you select either Workers' Compensation or No-Fault on this page, and then select No for the ORM Indicator on the ORM and TPOC Information page, and then click Next, you will see the following Warning, ORM Validation page: "Most Workers' Compensation and No-Fault cases involve ORM. You have indicated that ORM is not involved in the case you are reporting. If this is wrong, please select the Prev button and correct your record before submitting it, otherwise select the Next button."

Existing Claims: If you need to correct the ORM Indicator on a previously submitted and accepted claim, you must delete the previously reported record and then submit a new claim with the correct ORM Indicator.

Is the ORM terminated?

This field is required only if there was ORM for the claim. Answer yes if there is an termination date for the ORM or no if the termination date has not been determined.

ORM Termination Date

Date the ORM ended. This is only applicable to claims where the ORM indicator is equal to yes. Enter a valid date in MM/DD/CCYY format.

The termination date must be after the CMS Date of Incident. The date can be a future date, but it cannot be greater than 75 years from the current date.

TPOC Date(s)

Up to 5 TPOC dates can be reported. Enter a valid date in MM/DD/CCYY format. If a date is reported it must have a corresponding amount. TPOC dates are reportable regardless of ORM. This is the date that a payment obligation was established. This is the date the obligation is signed if there is a written agreement unless court approval is required. If court approval is required it is the later of the date of the obligation is signed or the date of court approval. If there is no written agreement it is the date the payment (or first payment if there will be multiple payments) is issued. At least one TPOC date and amount is required if there is not ORM.

TPOC Amount(s)

Up to 5 TPOC amounts can be reported. If a date is provided it must have a corresponding amount. Amounts can be entered with a decimal point but if none is entered two decimal positions will be added to the amount. Do not enter commas or dollar signs. Enter the dollar amount of the total payment obligation to the claimant for the TPOC date.

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. For annuities, base the total amount upon the time period used in calculating the purchase price of the annuity or the minimum payout amount (if there is a minimum payout), whichever calculation results in the larger amount. When the record includes information reflecting ORM (either current or terminated), only include amounts if there is a TPOC date/amount for a settlement, judgment, award, or other payment in addition to /apart from the information which must be reported with respect to responsibility for ongoing medicals.

Funding Delayed Beyond TPOC Start Date

Enter a date in MM/DD/CCYY format if the funding for the TPOC amount is delayed. Provide the actual or estimated date of funding. A date can be provided for each TPOC date/amount combination. Not valid without a corresponding TPOC date/amount.

Prev

Return to previous page (Injury Information page) without verifying information entered on this page.

SAVE

Save the information that you have entered and continue working on this page. The save will trigger edits if the information you have entered contains format or consistency errors.

SAVE & EXIT

Use this button to save your work to finish later. The application will save any information you have entered that does not have a data format error. You can then use the RESUME link for the partial claim on the Claim Listing page to complete your work later. This information will be available for 30 calendar days before it will be deleted.

CANCEL button

Takes you to the Cancel Confirmation page. Any information you entered will not be saved if you continue with the cancellation.

NEXT button

Submit information for verification and continue to the Insurance Information page if edits are passed.