Form N-2305 - Confirmation Of Msp Addendum
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1
2MEDICARE COMPLIANCE
The purpose of this communication is to notify employers of the mandatory reporting requirements of the Medicare,
Medicaid, and SCHIP Extension Act of 2007 which were passed into law in July 2008. Your cooperation in providing
the necessary employer data and data for each employee and dependent is needed in order to comply with the
requirements.
The Section 111 mandates of the law help payers identify when the Centers for Medicare and Medicaid Services (CMS)
should pay secondary to employer group health coverage. The goal includes reducing the amount CMS may pay as
primary when they should have paid as secondary.
Under the requirements, all health plan, liability, no fault and workers compensation coverages must register with CMS
as a Responsible Reporting Entity (RRE) and must report to CMS employer and member information. In order to fulfill
the mandated requirements and report accurately to CMS, Wellmark, as a RRE, must gather and groups must provide
the following information:
•
Employer Tax Identification Number (ETIN)
•
Evidence of status as a Commonly Owned/Controlled Group of Organizations, Multi/Multiple Employer
Group health plan (such as an Association or Trust), Hour Bank or Union health plan
•
Total number of group employees/group size
•
Social Security Numbers (SSNs) or Health Insurance Claim Numbers (HICNs) of active employees,
spouses, domestic partners
•
SSNs or HICNs for those dependents with end stage renal disease (ESRD) or disabled
•
Status of all employees and effective date of that status (i.e. active, COBRA, retired)
•
Disability information begin or end dates, if known
Please take a moment to complete the Confirmation of Medicare Secondary Payer (MSP) Addendum form. This will
allow us to capture your employer data for reporting to CMS. Member data is gathered through the use of the group’s
existing enrollment and eligibility data collection channels, which may include paper applications or electronic data
exchanges and should be provided through those processes.
Failure to provide the group information requested on the attached Confirmation of MSP Addendum can result in
penalties being assessed to the group including, but not limited to, $1,000 per day per member for not accurately
reporting to CMS and/or an excise tax equivalent to 25 percent of the employer’s group health plan expenses for the
relevant year.
Wellmark Blue Cross and Blue Shield of Iowa | 1331 Grand Avenue | PO Box 9232 | Des Moines, Iowa 50306-9232 |
N-2305 12/10
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