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Total Payment Obligation to Claimant (TPOC) threshold checks will be applied to liability insurance (including self-insurance) and workers’ compensation records where the Ongoing Responsibility for Medicals (ORM) Indicator is equal to ‘N’. Add records (initial claim reports) triggering this error will result in the message "The total TPOC amount is equal to or less than the mandatory reporting threshold."
The TPOC threshold check will only be applied to add records.
All TPOC amounts will be added and the sum compared to the threshold that applies to the latest, most recent TPOC Date submitted on the claim.
The TPOC threshold check only applies to liability and workers’ compensation claims (Plan Insurance Type of L or E). There is no threshold check for no-fault records.
Liability Reporting Requirements and Thresholds
| Reporting Required for Cumulative Total TPOC Amount(s) | Reporting Optional for Cumulative Total TPOC Amount(s) | Most Recent TPOC Date is on or between | Reporting Required Quarter Beginning | Threshold Error for Cumulative TPOC Amounts |
| Greater than $100,000 | From $5,000 to $100,000 | October 1, 2011 to March 31, 2012 | January 1, 2012 | Less than or equal to $5,000 |
| Greater than $50,000 | From $5,000 to $50,000 | April 1, 2012 to June 30, 2012 | July 1, 2012 | Less than or equal to $5,000 |
| Greater than $25,000 | From $5,000 to $25,000 | July 1, 2012 to Sept. 30, 2012 | October 1, 2012 | Less than or equal to $5,000 |
| Greater than $5,000 | From $300 to $5,000 | October 1, 2012 to Sept. 30, 2013 | January 1, 2013 | Less than or equal to $300 |
| Greater than $2,000 | From $300 to $2,000 | October 1, 2013 to Sept. 30, 2014 | January 1, 2014 | Less than or equal to $300 |
| Greater than $1,000 | NA | October 1, 2014 or after | January 1, 2015 | Less than or equal to $1,000 |
Workers’ Compensation Reporting Requirements and Thresholds
| Reporting Required for Cumulative Total TPOC Amount(s) | Reporting Optional for Cumulative Total TPOC Amount(s) | Most Recent TPOC Date is on or between | Reporting Required Quarter Beginning | Threshold Error for Cumulative TPOC Amounts |
|---|---|---|---|---|
| Greater than $5,000 | From $300 to $5,000 | October 1, 2010 to Sept., 30, 2013 | January 1, 2011 | Less than or equal to $300 |
| Greater than $2,000 | From $300 to $2,000 | October 1, 2013 to Sept. 30, 2014 | January 1, 2014 | Less than or equal to $300 |
| Greater than $300 | NA | October 1, 2014 or after | January 1, 2015 | Less than or equal to $300 |
Add and update records will be checked for a late submission of the ORM Termination Date. If the ORM Termination Date is more than 135 days prior to the date the claim is submitted by the RRE, a ‘03’ compliance code will be returned from the batch process. Compliance codes can be located on the bottom of the Claim Confirmation page. The late submission of an ORM Termination date compliance code is only applicable to claims completed with a 01 or 02 disposition code.
More information on TPOC dates and compliance can be found on the CMS website at https://www.cms.gov/medicare/coordination-benefits-recovery/mandatory-insurer-reporting. Please check there for the latest Alerts and instructions on the topic. The NGHP User Guide, linked in the left sidebar of that page, should also be reviewed for more specific guidance.
September 2024
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