Form CMS-10265 Interim Non-GHP Record Layout

MMSEA Section 111
MSP Mandatory Reporting
Interim Record Layout Information for:
•

Liability Insurance (Including Self-Insurance)

•

No-Fault Insurance

•

Workers’ Compensation

The complete Section 111 User Guide for Liability Insurance (Including
Self-Insurance), No-Fault Insurance, and Workers’ Compensation is in
process.
Note: This is a revised version of the Interim Record Layout dated November 17, 2008.
The version date is shown in the footer on the cover page for each version. Note that the
date for this version, as shown below, is December 5, 2008.
Revisions:
• Added detailed information regarding: “Who Is the Responsible Reporting Entity
(RRE)?”, “General Rules for Agents”, “High Level File Submission Rules”, and
“What Triggers Reporting?”
• Revisions to the File Layout include but are not limited to the following: elimination
of some fields associated with no-fault insurance; delay in requiring the reporting of
certain fields; re-naming the “Policyholder” information as “Self-Insurance”
information (with the applicable information requested only for self-insurance); and
optional use of free form text for a limited time period in lieu of providing the WCIO
Nature of Injury Code and the WCIO Cause of Injury Code and either an ICD-9 Code
or WCIO Body Part Code. See page 15 for a more detailed listing of revisions to the
File Layout.
Material in this document includes:
• Overview
• Who Is the Responsible Reporting Entity (RRE)?
• General Rules for Agents
• High Level File Submission Rules
• General Requirements for the Reporting Process
• What Triggers Reporting?
• File Layouts
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0938-1024 (Expires 04/30/2021). The time required to complete this information collection is estimated to
average 2.44 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments,
medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the
information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained.

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MMSEA Section 111 Mandatory Reporting - Liability Insurance
(Including Self-Insurance), No-Fault Insurance, Workers’
Compensation
Overview
Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA)
(P.L. 110-173), adds new Medicare Secondary Payer (MSP) mandatory reporting
requirements for group health plan (GHP) arrangements at 42 U.S.C. 1395y(b)(7) and for
liability insurance (including self-insurance), no-fault insurance, and workers’
compensation (sometimes collectively referred to as Non-Group Health Plan, Non-GHP
or NGHP) at 42 U.S.C. 1395y(b)(8).
The entities responsible for complying with the reporting requirements for Section 111
are referred to as Responsible Reporting Entities or RREs. This document provides
information on the file layouts that will be used by RREs for complying with the
reporting requirements at 42 U.S.C. 1395y(b)(8) for liability insurance (including selfinsurance), no-fault insurance, and workers’ compensation You must use the applicable
statutory language in conjunction with “Attachment A – Definitions and Reporting
Responsibilities” to the Supporting Statement for the Paperwork Reduction Act (PRA)
Notice published in the Federal Register. See Appendix A. in order to determine if you
are an RRE for purposes of these new provisions. The statutory language, the PRA
Notice and the PRA Supporting Statement with Attachments are all available as
downloads at www.cms.hhs.gov/MandatoryInsRep. "Attachment A" to the Supporting
Statement provides details on definitions and exactly which entities must report.
Complete instructions and requirements will be published at a later date in the MMSEA
Section 111 Liability Insurance (Including Self-Insurance), No-Fault Insurance, and
Workers’ Compensation User Guide, and this user guide will be available as a download
on the dedicated Section 111 Web page at www.cms.hhs.gov/MandatoryInsRep when
completed. RREs are encouraged to visit this site often for updates on Section 111
reporting requirements.
The purpose of the Section 111 MSP reporting process is to enable CMS to pay correctly
for Medicare covered items and services furnished to Medicare beneficiaries by
determining primary versus secondary payer responsibility. Section 111 requires RREs to
submit information specified by the Secretary in a form and manner (including
frequency) specified by the Secretary. The Secretary requires data for both Medicare
claims processing and for MSP recovery actions, where applicable. RREs will submit
information electronically on liability insurance (including self-insurance), no-fault
insurance, and workers’ compensation claims where the injured party is a Medicare
beneficiary. The actual data submission process will take place between the RREs and the

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CMS Coordination of Benefits Contractor (the COBC). The COBC will manage the
technical aspects of the Section 111 data submission process for all Section 111 RREs.
Note: For purposes of RRE submissions, the term “claim” is used to refer to the overall
claim for liability insurance (including self-insurance), no-fault insurance or workers’
compensation rather than a single claim for a particular medical item or service.
Section 111 RREs are required to register with the COBC and fully test the data
submission process before submitting production files. RREs will then be assigned a
quarterly file submission timeframe during which they are to submit files. Once in a
production mode, RREs will submit their initial files containing information for all
liability insurance (including self-insurance), no-fault insurance, and workers’
compensation claims involving a Medicare beneficiary as the injured party where the
settlement, judgment, award or other payment date is July 1, 2009, or subsequent, and
claims on which ongoing responsibility for medical payments exists as of July 1, 2009,
regardless of the date of an initial acceptance of payment responsibility. Subsequent
quarterly file submissions are to contain only new or changed claim information using
add, delete and update transactions.
The data necessary for the Section 111 NGHP reporting process is documented in the
attached record layouts. An RRE electronically transmits a data file to the COBC. The
COBC processes the data in this input file by first editing the incoming data. Other
insurance information for Medicare beneficiaries derived from the input file is posted on
the Medicare Common Working File (CWF) by the COBC for use by other Medicare
contractors for claims processing and/or passed to the CMS Medicare Secondary Payer
Recovery Contractor (MSPRC) for recovery efforts. When this processing is completed
or the prescribed time for response file generation has elapsed, the COBC electronically
transmits a response file back to the RRE. The response file will include information on
any errors found, disposition codes that indicate the results of processing, and MSP
information as prescribed by the response file format.

Who Is the Responsible Reporting Entity (RRE)?
•

42 U.S.C. 1395y(b)(8) defines a responsible reporting entity (RRE) to be an
applicable plan:
“APPLICABLE PLAN- In this paragraph, the term `applicable plan' means
the following laws, plans, or other arrangements, including the fiduciary or
administrator for such law, plan, or arrangement:
(i) Liability insurance (including self-insurance).
(ii) No fault insurance.
(iii) Workers' compensation laws or plans.”
As stated, you must use the applicable statutory language in conjunction with
“Attachment A – Definitions and Reporting Responsibilities” to the Supporting

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Statement for the Paperwork Reduction Act (PRA) Notice published in the Federal
Register in order to determine if you are a “responsible reporting entity” or “RRE” for
purposes of these new provisions. The statutory language, the PRA Notice and the
PRA Supporting Statement with Attachments are all available as downloads at
www.cms.hhs.gov/MandatoryInsRep. "Attachment A -- Definitions and Reporting
Responsibilities” to the Supporting Statement provides details on definitions and
exactly which entities must report.
CMS is aware that the industry generally does not use the term “plan” or some other
CMS definitions such as the definitions for “no-fault insurance” or “self-insurance.”
However, CMS is constrained by the language of the applicable statute and CMS’
regulations. It is critical that you understand and utilize CMS’ definitions for
purposes of Section 111 when reviewing and implementing Section 111 instructions.
•

Third party administrators (TPAs) as defined by CMS for purposes for 42 U.S.C.
1395y(b)(7) & (8) are never RREs for purposes of 42 U.S.C. 1395y(b)(8) [liability
(including self-insurance), no-fault, and workers’ compensation reporting] and only
act as agents for such reporting. The RRE is limited to the “applicable plan” and may
not by contract or otherwise limit its reporting responsibility although it may contract
with a TPA or other entity for actual file submissions for reporting purposes. The
applicable plan must either report directly or contract with the TPA or some other
entity to submit data as its agent. (Where an RRE uses another entity for claims
processing or other purposes, it may wish to consider contracting with that entity as
its agent for reporting purposes).

•

Where an entity is self-insured for a deductible but the payment of that deductible is
done through the insurer, then the insurer is responsible for including the deductible
amount in the amount it reports as a settlement, judgment, award or other payment.

•

Where there are multiple defendants involved in a settlement, an agreement to have
one of the defendant’s insurers issue any payment in obligation of a settlement,
judgment, award or other does not shift RRE responsibility to the entity issuing the
payment. All RREs involved in the settlement remain responsible for their own
reporting.

•

RRE in bankruptcy – CMS is considering whether or not special provisions must be
made for this situation.

•

Re-insurance, stop loss insurance, excess insurance, umbrella insurance, guaranty
funds, patient compensation funds which have responsibility beyond a certain limit,
etc. -- The key in determining whether or not reporting for 42 U.S.C. 1395y(b)(8) is
required for these situations is whether or not the payment is to the injured
claimant/representative of the injured claimant vs. payment being made to selfinsured entity to reimburse the self-insured entity. Where payment is being made to
reimburse the self-insured entity, the self-insured entity is the RRE for purposes of

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the payment made to the injured individual and no reporting is required by the insurer
reimbursing the self-insured entity.

General Rules for the Use of Agents for Section 111 Reporting
•

Agents are not Responsible Reporting Entities (RREs) for purposes of the MSP
reporting responsibilities for 42 U.S.C. 1395y(b)(7) & (8). However, the applicable
RRE may contract with an entity to act as an agent for reporting purposes.

•

Agents may include, but are not limited to, data service companies, consulting
companies or similar entities that can create and submit Section 111 files to the
COBC on behalf of the RRE.

•

Registration for reporting and file submission with the COBC must be completed by
the RRE. During registration, the RRE may designate an agent. An agent may not
register on behalf of an RRE.

•

An RRE may not shift its Section 111 reporting responsibility to an agent, by contract
or otherwise. The RRE remains solely responsible and accountable for complying
with CMS instructions for implementing Section 111 and for the accuracy of data
submitted.

•

CMS does not sponsor or partner with any entities that can be agents. CMS has not
and will not endorse any entity as an agent for Section 111 reporting purposes and has
no approved list of agents. Entities that are potential agents do not register with CMS
or pay CMS a fee in order to become an agent.

High Level File Submission Rules for Section 111 Reporting
•

CMS’ COBC will handle the technical aspects for reporting and for the management
of all file submissions.

•

RRE GHP file submissions may not be mixed with RRE NGHP (liability insurance
[including self-insurance], no-fault insurance, and workers' compensation) file
submissions.

•

An NGHP RRE may include liability insurance (including self-insurance), no-fault
insurance, and workers' compensation files in a single submission if it has
responsibility for multiple lines of business; however, there is no requirement to do
so. If separate files will be submitted by line of business, subsidiary or other reason,
then the RRE must register and obtain a Section 111 reporter ID for each file

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•

An NGHP RRE is to report the assumption or termination of “ongoing responsibility”
situations along with the one-time reporting of payments where ongoing
responsibility is not assumed.

•

The number of submissions per quarter made by a particular NGHP RRE will be a
consequence of how many lines of business it chooses to report separately; for a GHP
RRE the number of submissions per quarter will be dependent upon how the RRE
wishes to split its client base. An RRE may register separately for different lines of
business and/or different client bases (including identifying a different agent for data
submission for each registration). This could include registering at the parent
company level vs. registering at a subsidiary level.

•

An agent may not mix data for multiple RRE clients in the agent’s file submission.

•

Each registered RRE will be assigned a COBC EDI representative (EDI Rep). The
EDI Rep will assist with test and production file exchanges.

•

All reporting is to be through electronic file exchanges. CMS has made no plans for
direct data entry by RREs. (RREs who believe that their volume is too small to
report electronically directly may wish to contract with an agent for file submission.)

General Requirements for File Submission
•

Input Claim Files must include properly formatted header, detail and trailer records as
defined in the file layouts provided.

•

Input Claim Files must be submitted on a quarterly basis, four times a year.

•

Files must be submitted within an assigned, 7-day submission period each quarter.
File submission timeframes will be assigned after successful registration for Section
111 reporting.

•

RREs will be assigned a Section 111 Reporter ID during registration which is to be
used on all submitted files.

•

Section 111 liability insurance (including self-insurance), no-fault insurance, and
workers’ compensation RREs must submit their initial production Section 111 Input
Claim File during the fourth calendar quarter (October - December) of 2009 during
their assigned submission timeframe.

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•

RREs must register on the COB Secure Web site (COBSW) by June 30, 2009, and
complete testing prior to submission of production files. (The earliest date for
registration is May 1, 2009.) After the registration has been processed by the COBC,
the RRE will receive an e-mail with a Profile Report. The Profile Report will contain
information submitted during registration for verification purposes, the assigned 7day file submission timeframe, and the assigned Section 111 Reporter ID (RRE ID).
The last page of the Profile Report must be signed by the RRE and returned to the
COBC before testing can begin.

•

Files may be submitted via the COBSW using Hypertext Transfer Protocol over
Secure Socket Layer (HTTPS) or Secure File Transfer Protocol (SFTP). As an
alternative, RREs with large amounts of data may submit via Connect:Direct
(formerly known as NDM) via the AT&T Global Network System (AGNS). To use
the AGNS method, RREs must first establish an AGNS account in order to send files
directly to the COBC over AGNS. RREs that currently do not have an existing AGNS
account should contact one of the well-established resellers of AT&T services to
obtain a dedicated or a dial-up access line to the AGNS VAN. RREs are encouraged
to do this as soon as possible since this set up can take a significant amount of time.
o Files submitted via HTTPS or uploaded via SFTP to the COBC secured web site
should utilize an ASCII format. Fields within the records are length delimited and
all records are fixed length.
o Files transmitted directly to the COBC mainframe using Connect:Direct will be
automatically converted to EBCDIC.

•

RREs must implement a procedure in their claims resolution process to determine
whether an injured party is a Medicare beneficiary. RREs must submit either the
Social Security Number (SSN) or Medicare Health Insurance Claim Number (HICN)
for the injured party on all Input Claim File detail records.

•

RREs’ initial file submissions must report on all claims, where the injured party
is/was a Medicare beneficiary, that are resolved (or partially resolved) through a
settlement, judgment, award or other payment on or after July 1, 2009, regardless of
the assigned date for a particular RREs first submission. This includes resolution (or
partial resolution) through one payment obligation (regardless of whether the
payment obligation is executed through a single payment, a structured settlement, or
an annuity) as well as those situations where there is a responsibility for ongoing
medical services.

•

RREs must also report on claims for which the RRE still has responsibility for
ongoing payments for medical services as of July 1, 2009, regardless of an initial
resolution (partial resolution) date prior to July 1, 2009. (See the associated special
reporting extension discussed in “What Triggers Reporting” later in this document.)

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•

If an RRE has accepted Ongoing Responsibility for Medical payments (ORM) on a
claim, then the RRE must report two events; an initial record to reflect the acceptance
of ongoing payment responsibility and a second (final) record to reflect the end date
of ongoing payment responsibility with the corresponding end date reflected in the
ORM Termination Date (Field 77). Because reporting is done only on a quarterly
basis, there may be some situations in which the RRE reports the assumption of
ongoing responsibility in the same record as which a termination date for such
responsibility. RREs are not to submit a report on the Input Claim File every time a
payment is made for situations involving ongoing payment responsibility.

•

A Federal Tax Identification Number (TIN) Reference File must be submitted with
the Initial Claim File containing records for each plan TIN submitted in Field 50 of
Claim File detail records. For those who are self-insured, their TIN may be an
Employer Identification Number (EIN) or Social Security Number (SSN) depending
upon their particular situation.

•

All combinations of Plan TIN and Office Code/Site ID submitted in Fields 50 and 51
of the Claim File detail records must have a corresponding TIN/Site ID combination
on the TIN Reference File. For example, an RRE may use only one TIN (123456789)
but have two office codes or site IDs; 01 for Workers’ Compensation claims and 02
for Commercial Liability Claims. Two records will be reported on the TIN Reference
File. One record with TIN of 123456789 and Office Code/Site ID of 01 and a second
record with the same TIN of 123456789 but Office Code/Site ID of 02. Different
mailing addresses may be submitted on the TIN Reference File for each of these
entries. In this example, the RRE would submit 123456789 in Field 50 of each claim
detail record, 01 in Field 51 of each Workers’ Compensation claim detail record, and
02 in Field 51 of each Commercial Liability claim detail record.

•

Subsequent Claim Files do not need to be accompanied by a TIN Reference File
unless changes to previously submitted TIN/Office Code/Site ID information must be
submitted or new TIN/Office Code/Site ID combinations have been added.
Subsequent quarterly update files must include records for any new claims, where the
injured party is a Medicare beneficiary, reflecting settlement, judgment, award, or
other payment since the last file submission. However, if the settlement, judgment,
award or other payment is within 45 days prior to the start of the 7-day file
submission timeframe, then an RRE may submit that claim on the next quarterly file.
This grace period allows the RRE time to process the newly resolved (partially
resolved) claim information internally prior to submission for Section 111. For
example, if the settlement date is May 1, 2010, and the file submission period for the
second calendar quarter of 2010 is June 1-7, 2010, then the RRE may delay reporting
that claim until the third calendar quarter file submission during September 1-7, 2010.
However, if the settlement date is April 1, 2010, then the RRE must include this claim
on the second calendar quarter file submission during June 1-7, 2010. Records not
received timely will be processed but marked as late and used for subsequent
compliance tracking. A code indicating a late submission was received will be placed

•

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in the first available Compliance Flag (Fields 36 – 45) of the corresponding Claim
Response File Detail record.
•

Subsequent quarterly update files must include pertinent updates/corrections/deletions
to any previously submitted records.

•

Quarterly update files must contain resubmission of any records found in error on the
previous file with corrections made. No interim file submissions will be accepted.

•

If you have no new information to supply on a quarterly update file, you must submit
an “empty” Claim Input File with a header record, no detail records, and a trailer
record that indicates a zero detail record count.

•

E-mail notifications will be sent to the Section 111 RRE contacts after a file has been
initially processed and when a response file has been transmitted or is available for
download.

•

Each detail record on the Input Claim File must contain a unique Document Control
Number (DCN) generated by the RRE. This DCN is required so that response records
can be matched and issues with files more easily identified and resolved. It can be any
format of the RREs choosing as long as it is not more than 15 alpha-numeric
characters as defined in the record layout. Most of CMS’ current data exchange
partners use some form of a Julian date and a counter as their DCN.

•

The COBC will return response files to the RRE within 45 days of the receipt date
posted for the input file.

What Triggers Reporting
In general, reporting for purposes of 42 U.S.C. 1395y(b)(8) (vs. 1395y(b)(7)) is
somewhat different because coverage for liability insurance (including self-insurance),
no-fault insurance, and workers’ compensation situations is incident specific rather than
the type of ongoing coverage provided by GHP coverage.
•

RREs are to report only with respect to Medicare beneficiaries (including a
deceased beneficiary if the individual was deceased at the time of the settlement,
judgment, award or other payment). If a reported individual is not a Medicare
beneficiary or CMS is unable to validate a particular SSN or HICN based upon
the submitted information, CMS will reject the record for that individual. The
Applied Disposition Code (Field 25) on the corresponding Claim Response File
detail record will indicate the reason for rejection.

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•

RREs are to report once there has been a settlement, judgment, award or other
payment. Notice to CMS of a pending claim or other pending action does not
satisfy an RRE’s reporting obligations with respect to 42 U.S.C. 1395y(b)(8).

•

Records are submitted on a beneficiary-by-beneficiary basis, by type of insurance,
by policy number, by RRE, etc. Consequently, it is possible that an RRE will
submit more than one record for a particular individual in a particular quarter’s
submission window. For example if there is an automobile accident with both
drivers insured by the same company and both drivers’ polices are making
payment with respect to a particular beneficiary, there would be a record with
respect to each policy. There would also be two records with respect to a single
policy if the policy were reporting a med pay (considered to be no-fault)
assumption of ongoing responsibility for medicals and/or exhaustion/termination
amount as well as a liability settlement/judgment/award/other payment in the
same quarter.
o Joint settlements, judgments, awards, or other payments -- Each RRE reports
its ongoing medical responsibility and/or its settlement/judgment/award/other
payment responsibility without regard to ongoing medicals. Each RRE would
also report any responsibility it has for ongoing medicals on a policy-bypolicy basis. Again, depending on the number of policies at issue for an RRE
and/or the type of insurance or workers’ compensation involved, an RRE may
be submitting multiple records for the same individual.
o Multiple settlements involving the same individual -- Each RRE must report
appropriately. There will be multiple records submitted for the same
individual but they will be cumulative rather than duplicative. Additionally, if
more than one RRE has assumed responsibility for ongoing medicals,
Medicare would be secondary to each such entity and would build a separate
MSP occurrence in CMS’ common Working File for each submission.
o Re-insurance, stop loss insurance, excess insurance, umbrella insurance
guaranty funds, patient compensation funds which have responsibility beyond
a certain limit, etc. -- The key in determining whether or not reporting for 42
U.S.C. 1395y(b)(8) is required for these situations is whether or not the
payment is to the injured claimant/representative of the injured claimant vs.
payment being made to self-insured entity to reimburse the self-insured entity.
Where payment is being made to reimburse the self-insured entity, the selfinsured entity is the RRE for purposes of the payment made to the injured
individual and no reporting is required by the insurer reimbursing the selfinsured entity.
o One time payment for defense evaluation - A payment made specifically for
this purpose directly to the provider or other physician furnishing this service
does not trigger the requirement to report.

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•

RREs must report required data as of July 1, 2009, regardless of the date of the
RRE’s first assigned file submission window. This includes claims pending a
settlement, judgment, award, or other payment as of July 1, 2009, or later, as well
as claims for which ongoing responsibility for medicals was established/accepted
prior to July 1, 2009.
o Where ongoing responsibility for Medicals has been assumed, the RRE must
report two events -- when the responsibility is assumed and when the
responsibility is terminated. The RRE does not report specific dollar amounts
paid for individual bills for services to these individuals. The RRE will
normally have to make two reports for such individuals although it is possible
that both events could be reported in a single submission, depending upon the
timing of the submission.
Where ongoing responsibility for medicals was assumed prior to July 1, 2009,
and continues on as of July 1, 2009, the RRE must report this individual. As
RREs may not have collected the necessary data elements for individuals for
whom responsibility was assumed prior to July 1, 2009, CMS is permitting
RREs to delay reporting for these individuals until the RRE’s assigned
submission in the third calendar quarter (July – October) of 2010. The
extension is intended to allow RREs time to go back and determine the
Medicare status of individuals for whom there is pre-existing ongoing
payment responsibility which continues as of July 1, 2009. This extension
does not apply to claims with resolution (partial resolution) dates of July 1,
2009, and subsequent. The extension applies only to claims where the RRE
has accepted ongoing responsibility, with the claim potentially subject to
further payment as of 7/1/09, but the original resolution (partial resolution)
date is prior to 7/1/09. If an RRE has the information that such a claimant is a
Medicare beneficiary and the RRE has the SSN or HICN, it is to send the
record with its initial file in fourth calendar quarter 2009. If the RRE does not
have this information, it may delay reporting on these claims until its third
calendar quarter 2010 file submission.
If the individual was not a Medicare beneficiary at the time responsibility for
ongoing medicals was assumed, the RRE must monitor the status of that
individual and report when that individual becomes a Medicare beneficiary
unless responsibility for ongoing medicals has terminated before the
individual becomes a Medicare beneficiary.
o Where payment is made pending investigation, the RRE must report this as an
assumption of responsibility for ongoing medicals. If responsibility for
ongoing medicals terminates upon completion of the investigation, the
termination of responsibility for ongoing medicals must be reported.

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•

Where there is a settlement, judgment, award or other payment with no
establishment/acceptance of responsibility for ongoing medicals, the RRE is not
required to report for purposes of 42 U.S.C. 1395y(b)(7) & (8) if the individual is
not a Medicare beneficiary as of the date which must be reported for the
settlement, judgment, award, or other payment.

•

RREs must report settlements, judgments, awards, or other payments regardless
of whether or not there is an admission or determination of liability. Reports
are required with either partial or full resolution of a claim.
o For purpose of the required reporting for 42 U.S.C. 1395y(b)(8), the RRE
does not make a determination of what portion of any settlement, judgment,
award, or other payment is for medicals and what portion is not.
The RRE reports responsibility for ongoing medicals separately from any
other payment obligation but does not separate medical vs. non medical issues
if medicals have been claimed and/or released or the settlement, judgment,
award, or other payment otherwise has the effect of releasing medicals.
o There is no exception to the reporting requirements for alleged de minimus or
“nuisance” settlements, judgments, awards or other payments. (CMS is
gathering data related to this issue and will issue instructions if it adopts a de
minimus or “nuisance value” exception for reporting purposes.)
o “No medicals” – If medicals are claimed and/or released, the settlement,
judgment, award or other payment must be reported regardless of any
allocation made by the parties or a determination by the court.
-

The CMS is not bound by any allocation made by the parties even where a
court has approved such an allocation. (The CMS does normally defer to
an allocation made through a jury verdict or after a hearing on the merits.
However, this issue is relevant to whether or not CMS has a recovery
claim with respect to a particular settlement, judgment, award or other
payment and does not affect the RRE’s obligation to report.)

-

RREs are not required to report liability insurance (including selfinsurance) settlements, judgments, awards or other payments for “property
damage only” claims which did not claim and/or release medicals or have
the effect of releasing medicals.

o RREs must report the full amount of any settlement, judgment, award or other
payment without regard to any amount separately obligated to be paid as a
result of the assumption/establishment of responsibility for ongoing medicals.
•

“Date of Incident” prior to December 5, 1980 – The date of incident does not
affect the RRE’s reporting responsibilities for workers’ compensation. Medicare
has been secondary to workers’ compensation from the inception of the Medicare

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program. However, the liability insurance and no-fault insurance MSP provisions
were effective December 5, 1980. CMS has determined as a matter of policy that
it will not recover under the MSP provisions with respect to liability insurance
(including self-insurance) or no-fault settlements, judgment, or awards where the
date of incident as defined by CMS was prior to December 5, 1980.
Consequently, the RRE is not required to report liability insurance (including selfinsurance) or no-fault insurance settlements, judgments, awards or other payments
where the date of incident was prior to December 5, 1980.
o For claims involving “exposure”, this means that there was no exposure on or
after December 5, 1980, alleged, established, and/or released. If any exposure
for 12/5/80 or later was claimed and/or released, then Medicare has a potential
recovery claim and the RRE must report for Section 111 purposes.
•

Policies or self-insurance allegedly “supplemental” to Medicare -- By statute,
Medicare is secondary to liability insurance (including self-insurance), no-fault
insurance, and workers' compensation. An insurer cannot, by contract, supersede
federal law.

•

There is no age threshold for reporting for 42 U.S.C. 1395y(b)(8).

•

The geographic location of the incident, illness, injury is not determinative of the
RRE’s reporting responsibility as Medicare beneficiaries who are injured or
become ill outside of the United States often return to the U.S. for medical care.

•

No settlement, judgment, award, other payment and “file is ready to be closed” -Where there is no settlement, judgment award or other payment, including an
assumption of responsibility for ongoing medicals, there is no report required.
o With respect to responsibility for ongoing medicals, a determination that a
case is “closed” or otherwise inactive does not automatically equate to a report
terminating the responsibility for ongoing medicals. If the responsibility for
ongoing medicals is subject to reopening or otherwise subject to a further
request for payment, the record submitted for responsibility for ongoing
medicals should remain open. (Medicare beneficiaries have a continuing
obligation to apply for all no-fault or workers’ compensation benefits to which
they are entitled.) Similarly, if a file is “closed” due to a “return to work” and
no additional anticipated medicals, a report terminating the responsibility for
ongoing medicals should not be submitted as long as the responsibility for
ongoing medicals is subject to reopening or otherwise subject to an additional
request for payment.
o For liability insurance (including self-insurance) each new payment obligation
must be reported as a separate settlement, judgment, award, or other payment.
Note: Where a payment obligation is satisfied through a structured settlement

MMSEA111NGHPFileLayoutsInterim20081205

13

or purchase of an annuity, there is a single report with respect to the total
amount of the obligation.
•

Mass torts or Multi-District Litigation (MDL) – CMS is seeking input from the
industry and will work with the industry regarding the most efficient way for
reporting to occur in such situations. Reporting is required, but CMS recognizes
that it may have to issue special instructions for such situations.

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NGHP File Layout Pages
Changes made since November 17, 2008 posting:
• Input Claim File record length increased to 2220 bytes.
• Document Control Number (DCN) increased to 15 bytes (Claim Detail Field 2,
Claim Auxiliary Field 2 and Claim Response Field 2).
• Fields on the Claim Detail record renumbered and starting and ending positions
adjusted.
• Added a value of ‘0’ for Unknown to Claim Detail Injured Party Gender Field 9.
• Description of Claim Detail Field 12 changed to CMS Date of Incident.
• Added Field 13 Industry Date of Incident to Claim Detail record.
• Renamed Claim Detail Fields 14 and 16 to Alleged Nature and Alleged Cause of
Injury, Incident, Illness.
• Descriptions of Claim Detail Fields 14, 16, 20, 30, 35, 37, 38, 39, 40, and 65
changed to add requirements effective January 1, 2011.
• Clarification added to description of Claim Detail State of Venue Field 18.
• Additional filler added after Claim Detail ICD-9 Diagnosis Code Fields 20-28 to
allow for future expansion for submission of ICD-10 Diagnosis Codes.
• Values of Claim Detail Product Liability Indicator Field 36 changed.
• Modified requirements for Claim Detail Product Liability Fields 37-40.
• Descriptions of Claim Detail Policyholder Fields 42-47 modified to require
policyholder information for self-insured situations only.
• Claim Detail Office/Site Code Field 51, Plan Contact Department Name Field 54,
and Plan Contact Phone/Extension Fields 57/58 changed from required to
optional.
• Claim Detail and Auxiliary Representative Firm Name Fields changed to be
required as of January 1, 2011.
• No-Fault Insurance Arrangement Indicator, Specified Medicals Cap Amount and
associated Exhaust Date field removed from Claim Detail record.
• Ten Compliance Flag fields added to the end of the Claim Response File Detail
record using existing filler.

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MMSEA Section 111 Mandatory Reporting - Liability
Insurance (Including Self-Insurance), No-Fault
Insurance, Workers’ Compensation
Input Claim File Layout

MMSEA Section 111
Liability Insurance (Including Self-Insurance), No-Fault Insurance, Workers’
Compensation Input Claim File Header Record – 2220 bytes

Field
No.

1

Name

Size

Start
Pos.

End
Pos.

Record
Identifier

4

1

4

Data
Type

Alphanumeric

Description

Must be ‘NGCH’.

Required.
13 Numeric COBC assigned Section
111Reporter ID #.

2

Section 111
Reporter ID

9

5

3

Section 111
Reporting
File Type
File
Submission
Date

7

14

20

8

21

Required.
28 Numeric Date file was transmitted to the
Date
COBC.

4

Alphanumeric

Required.
Must be ‘NGHPCLM’.

Format: CCYYMMDD

5

Reserved
for Future
Use

2192

29 2220

MMSEA111NGHPFileLayoutsInterim20081205

Alphanumeric

16

Required.
Fill with spaces.

MMSEA Section 111
Liability Insurance (Including Self-Insurance) No-Fault Insurance, Workers’
Compensation Input Claim File Detail Record – 2220 bytes

Field
No.

1

2

3

Name

Size

Start
Pos.

End
Pos.

Data
Type

Description

Injured Party/Medicare Beneficiary Information
(The injured party is/was a Medicare beneficiary.)
Record Identifier
4
1
4
AlphaMust be 'NGCD'.
numeric
Required.
DCN
15
5
19
AlphaDocument Control
numeric Number; assigned by the
Section 111 RRE.
Each record shall have a
unique DCN. DCN will be
supplied back by COBC
on corresponding
response file records for
tracking purposes.

Action Type

1

20

20

Numeric

Required.
Action to be performed.
Valid values:
0 = Add
1 = Change/Update
2 = Delete

4

Injured Party
HICN

12

21

32

Alphanumeric

Required.
Medicare Health
Insurance Claim Number
Fill with spaces if
unknown.
Required if SSN not
provided.

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Field
No.

Name

5

Injured Party SSN

Size

Start
Pos.

End
Pos.

9

33

41

Data
Type
Alphanumeric

Description

Social Security Number
Required if HICN not
provided.
Fill with spaces if
unknown and HICN
provided.
Surname of Injured Party

6

Injured Party Last
Name

40

42

81

Alphabetic

7

Injured Party First
Name

30

82

111

Alphabetic

Required.
Given or first name of
Injured Party.

8

Injured Party
Middle Init

1

112

112

Alphabetic

Required.
First letter of Injured Party
middle name.
Fill with space if unknown.

9

Injured Party
Gender

1

113

113

Numeric

Code to reflect the sex of
the injured party.
Valid values:
1 = Male
2 = Female
0 = Unknown
Default to 0, if unknown.

10

Injured Party
DOB

8

114

121

Numeric
Date

Required.
Date of Birth of Injured
Party
Format: CCYYMMDD

11

Reserved for
Future Use

20

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122

141

18

Alphanumeric

Required.
Fill with spaces.

Field
No.

12

Name

Size

Start
Pos.

End
Pos.

Data
Type

Description

Injury/Incident/Illness Information
CMS Date of
8
142
149 Numeric Date of Incident (DOI) as
Incident (DOI):
Date
defined by CMS: For an
automobile wreck or other
DOI as defined by
accident, the date of
CMS
incident is the date of the
accident. For claims
involving exposure
(including, for example,
occupational disease and
any associated cumulative
injury) 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).
Note: CMS’ definition of
DOI differs from the
definition routinely used
by the insurance/workers’
compensation industry
(Field 13) only for claims
involving exposure,
ingestion, or implants.
Format: CCYYMMDD
Required.

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Field
No.

Name

13

Industry Date of
Incident
(DOI): DOI
routinely used by
the
insurance/worker
s’ compensation
industry

Size

Start
Pos.

End
Pos.

8

150

157

Data
Type
Numeric
Date

Description

Date of Incident (DOI)
used by the
insurance/workers’
compensation industry:
For an automobile wreck
or other accident, the date
of incident is the date of
the accident. For claims
involving exposure,
ingestion, or implantation,
the date of incident is the
date of last exposure,
ingestion, or implantation.
Note: The definition of
DOI routinely used by the
insurance/workers’
compensation industry
DOI differs from the
definition which CMS must
use (Field 12 ) only for
claims involving exposure,
ingestion, or implants.

Format: CCYYMMDD
Optional.

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20

Field
No.

Name

14

Alleged Nature of
Injury, Incident,
Illness

Size

Start
Pos.

End
Pos.

2

158

159

Data
Type
Numeric

Description

Workers’ Compensation
Insurance Organization
(WCIO) Nature of Injury
Code.
Report the 2-digit code
that corresponds to the
nature of the injury
sustained by the injured
party/claimant.
For all claim types
including Liability, NoFault, and Workers’
Compensation. Refer to
https://www.iisprojects.co
m/WCIO/pub/PNC/WCIO_
Nature_Table.pdf.
Required for new claim
records submitted on or
after January 1, 2011.
See Field 35 for interim
requirement.

15

Reserved for
Future Use

2

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160

161

21

Alphanumeric

Fill with spaces.

Field
No.

Name

16

Alleged Cause of
Injury, Incident, or
Illness

Size

Start
Pos.

End
Pos.

2

162

163

Data
Type
Numeric

Description

Workers’ Compensation
Insurance Organization
(WCIO) Cause of Injury
Code.
Report the 2-digit code
that corresponds to the
cause of the injury.
For all claim types
including Liability, NoFault, and Workers’
Compensation. Refer to
https://www.iisprojects.co
m/WCIO/pub/PNC/WCIO_
Cause_Table.pdf.

17

Reserved for
Future Use

2

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164

165

22

Alphanumeric

Required for New Claim
Records Submitted on
or after January 1, 2011.
See Field 35 for interim
requirement.
Fill with spaces.

Field
No.
18

Name

State of Venue

Size

Start
Pos.

End
Pos.

Data
Type

2

166

167

Alphabetic

Description

US postal abbreviation
corresponding to the US
State whose state law
controls resolution of the
claim.
Insert “US” where the
claim is a Federal Tort
Claims Act liability
insurance matter or a
Federal workers’
compensation claim.
If the state of venue is in
dispute at the time an
RRE reports acceptance
on ongoing responsibility
for medicals, the RRE
should use its best
judgment regarding the
state of venue and submit
updated information, if
applicable, when the
ongoing responsibility is
terminated or further
reporting is required
because of a settlement,
judgment, award or
payment other than
payment made under the
ongoing responsibility for
medicals.

19

Reserved for
Future Use

1

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168

168

23

Alphanumeric

Required.
Fill with spaces. . For
future expansion to ICD10 Diagnosis Codes.

Field
No.
20

Name

ICD-9 Diagnosis
Code 1

Size

Start
Pos.

End
Pos.

5

169

173

Data
Type

Description

Alphanumeric

ICD-9-CM (International
Classification of Diseases,
Ninth Revision, Clinical
Modification) Diagnosis
Code describing the
alleged injury/illness.
Refer to
http://www.cdc.gov/nchs/d
atawh/ftpserv/ftpicd9/icdg
uide08.pdf and
http://www.cdc.gov/nchs/d
atawh/ftpserv/ftpicd9/ftpic
d9.htm.
At least one ICD-9
Diagnosis Code or Body
Part Code (Field 30) is
required.

21

Reserved for
Future Use

2

174

175

Alphanumeric

22

ICD-9 Diagnosis
Code 2

5

176

180

Alphanumeric

23
24

25

Reserved for
Future Use
ICD-9 Diagnosis
Code 3

Reserved for
Future Use

2

181

182

5

183

187

2

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188

189

24

Alphanumeric
Alphanumeric

Alphanumeric

Required for New Claim
Records Submitted on
or after January 1, 2011
if no Body Part Code 1
provided. See Field 35
for interim requirement.
Fill with spaces. For future
expansion to ICD-10
Diagnosis Codes.
See explanation for Field
20.
Provide if
available/applicable.
Fill with spaces.
See explanation for Field
20.
Provide if
available/applicable.
Fill with spaces.

Field
No.
26

27
28

Name

ICD-9 Diagnosis
Code 4

Reserved for
Future Use
ICD-9 Diagnosis
Code 5

29

Reserved for
Future Use

30

Body Part Code 1

Size

Start
Pos.

End
Pos.

5

190

194

2

195

196

5

197

201

Data
Type
Alphanumeric

Alphanumeric
Alphanumeric

142

202

343

Alphanumeric

3

344

346

Alphanumeric

Description

See explanation for Field
20.
Provide if
available/applicable.
Fill with spaces.
See explanation for Field
20.
Provide if
available/applicable.
Fill with spaces. For future
expansion to ICD-10
Diagnosis Codes.
Code corresponding to the
part of the body allegedly
injured.
Refer to
https://www.iisprojects.co
m/WCIO/pub/PNC/WCIO_
Part_Table.pdf.
At least one ICD-9
Diagnosis Code 1 (Field
20) or Body Part Code 1 is
required.

31

Body Part Code 2

3

347

349

Alphanumeric

Required for New Claim
Records Submitted on
or after January 1, 2011.
See Field 35 for interim
requirement.
Code corresponding to the
part of the body injured.
Refer to
https://www.iisprojects.co
m/WCIO/pub/PNC/WCIO_
Part_Table.pdf.
Provide if
available/applicable.

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25

Field
No.

Name

32

Body Part Code 3

Size

Start
Pos.

End
Pos.

3

350

352

Data
Type

Description

Alphanumeric

Code corresponding to the
part of the body injured.
Refer to
https://www.iisprojects.co
m/WCIO/pub/PNC/WCIO_
Part_Table.pdf.

33

Body Part Code 4

3

353

355

Alphanumeric

Provide if
available/applicable.
Code corresponding to the
part of the body injured.
Refer to
https://www.iisprojects.co
m/WCIO/pub/PNC/WCIO_
Part_Table.pdf.

34

Body Part Code 5

3

356

358

Alphanumeric

Provide if
available/applicable.
Code corresponding to the
part of the body injured.
Refer to
https://www.iisprojects.co
m/WCIO/pub/PNC/WCIO_
Part_Table.pdf.
Provide if
available/applicable.

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26

Field
No.
35

Name

Description of
Illness/Injury:

Size

Start
Pos.

End
Pos.

Data
Type

Description

50

359

408

Alphanumeric

Free-form text description
of illness or injury.
Include description of
major body part injured
(e.g. head, arm, leg, etc.)

(Temporary field
available through
December 31,
2010. This Field
will be re-labeled
for records
submitted on or
after January 1,
2011, as
"Reserved for
Future Use")

36

Product Liability
Indicator

Required through
December 31, 2010, if no
Nature of Injury Code
and a Cause of Injury
Code and either ICD-9
Diagnosis Code 1 or
Body Part Code 1
provided.

1

409

409

Alphanumeric

NOTE: The Description
for this Field will be
changed for records
submitted on or after
January 1, 2011, to read
"Fill With Spaces"
Indicates whether injury,
illness or incident was
allegedly caused
by/contributed to by a
particular product. Some
product liability situations
involve a product which
allegedly results in
situations involving falls or
other accidents. Others
may involve exposure to,
implantation of, or
ingestion of a particular
product.
Valid values:
1 = No
2 = Yes, but not a mass
tort situation.
3 = Yes, and is a mass
tort situation.
Required.

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27

Field
No.
37

Name

Product Generic
Name

Size

Start
Pos.

End
Pos.

40

410

449

Data
Type
Alphanumeric

Description

Generic name of product
alleged to be cause of
injury, illness or incident.
If no generic name
applicable, supply brand
name.
Required if Product
Liability Indicator (Field
36) is 3 (mass tort).

38

Product Brand
Name

40

450

489

Alphanumeric

Required for New Claim
Records Submitted on
or after January 1, 2011,
if Product Liability
Indicator is 2 or 3.
Brand name of product
alleged to be cause of
injury, illness or incident.
Required if Product
Liability Indicator (Field
36) is 3.

39

Product
Manufacturer

40

490

529

Alphanumeric

Required for all New
Claim Records
Submitted on or after
January 1, 2011, if
Product Liability
Indicator is 2 or 3.
Maker of product named
in Fields 37 and/or 38
above.
Required if Product
Liability Indicator (Field
36) is 3.
Required for all New
Claim Records
Submitted on or after
January 1, 2011, if
Product Liability
Indicator is 2 or 3.

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28

Field
No.
40

Name

Product Alleged
Harm

Size

Start
Pos.

End
Pos.

200

530

729

Data
Type

Description

Alphanumeric

Free-form description of
harm allegedly caused by
product named in Fields
37 and/or 38 above.
Required if Product
Liability Indicator (Field
36) is 3.

41

Reserved for
Future Use

20

MMSEA111NGHPFileLayoutsInterim20081205

730

749

29

Alphanumeric

Required for all New
Claim Records
Submitted on or after
January 1, 2011, if
Product Liability
Indicator is 2 or 3.
Fill with spaces.

Field
No.

Name

Size

Start
Pos.

End
Pos.

Data
Type

Description

Self-Insurance Information – Information required to: 1) indicate if the reportable
event involves “self-insurance” as defined by CMS; and 2) if yes, specific
information regarding the self-insured individual or entity.
42
Self Insured
1
750
750
AlphaIndication of whether the
Indicator
numeric reportable event involves
self-insurance as defined
by CMS.
Valid values:
Y = Yes
N = No
Self-insurance is defined
in “Attachment A –
Definitions and Reporting
Responsibilities” to the
Supporting Statement for
the FR PRA Notice (CMS10265) for this mandatory
reporting and is available
at
https://www.cms.hhs.gov/
MandatoryInsRep/Downlo
ads/SupportingStatement
082808.pdf.
Required if Plan
Insurance Type (Field
49) is E or L (Workers’
Compensation or
Liability).
43

Self-Insured Type

1

751

751

Alphanumeric

Identifies whether the selfinsured is an organization
or individual.
Valid values:
I = Individual
O = Other than Individual
(e.g. Business,
corporation, organization,
company, etc.)
Required if Self Insured
Indicator (Field 42) is Y.

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30

Field
No.

Name

44

Policyholder Last
Name

45

46

Policyholder First
Name

DBA Name

Size

Start
Pos.

End
Pos.

Data
Type

40

752

791

Alphabetic

30

70

792

822

821

891

Alphabetic

Alphanumeric

Description

Surname of policyholder.
Required if Self-Insured
Type (Field 43) = I.
Given/First name of
policyholder.
Required if Self-Insured
Type (Field 43) = I.
“Doing Business As”
Name of self-insured
organization/business.
DBA Name or Legal
Name is required for SelfInsured Type = O.

47

Legal Name

70

892

961

Alphanumeric

Required if Self-Insured
Type (Field 43) = O and
Legal Name (Field 47)
not provided.
Legal Name of selfinsured
organization/business.
DBA Name or Legal
Name is required for SelfInsured Type = O.

48

Reserved for
Future Use

20

MMSEA111NGHPFileLayoutsInterim20081205

962

981

31

Alphanumeric

Required if Self-Insured
Type (Field 43) = O and
DBA Name (Field 46) not
provided.
Fill with spaces.

Field
No.

49

Name

Plan Insurance
Type

Size

Start
Pos.

End
Pos.

Data
Type

Plan Information
1
982
982
Alphanumeric

Description

Type of insurance
coverage or line of
business provided by the
plan policy or selfinsurance.
Valid values:
D = No-Fault
E = Workers’
Compensation
L = Liability
Required.
Note: When selecting
“no-fault” as the type of
insurance, you must use
the CMS definition of “nofault” insurance found at
42 CFR 411.50. This
definition is different from
the industry definition
which is generally limited
to certain automobile
insurance.
“No fault insurance means
insurance that pays for
medical expenses for
injuries sustained on the
property or premises of
the insured, or in the use,
occupancy, or operation of
an automobile, regardless
of who may have been
responsible for causing
the accident. This
insurance includes but is
not limited to automobile,
homeowners, and
commercial plans. It is
sometimes called ‘medical
payments coverage’,
‘personal injury
protection’, or ‘medical
expense coverage.’ See
42 CFR 411.50”

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32

Field
No.
50

Name

TIN

Size

Start
Pos.

End
Pos.

9

983

991

Data
Type

Description

Numeric

Federal Tax Identification
Number of the “applicable
plan,” whether liability
insurance (including selfinsurance), no-fault
insurance or a workers’
compensation law or plan.
Must have a
corresponding entry with
associated Office
Code/Site ID on the TIN
Reference File.

51

Office Code/Site
ID

9

992

1000

AlphaNumeric

Required.
RRE-defined code to
uniquely identify variations
in insurer addresses/claim
offices/Plan Contact
Addresses. Defined by
RRE. Used to uniquely
specify different
addresses associated with
one TIN.
If only one address will be
used per reported TIN,
leave blank.
Must have a
corresponding entry with
associated TIN on the TIN
Reference File. A record
must be submitted on the
TIN Reference File for
each unique TIN/Site ID
combination.
Optional.

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33

Field
No.

Name

Size

Start
Pos.

End
Pos.

Data
Type

Description

The unique identifier for
the policy under which the
underlying claim was filed.
RRE defined. If liability
self-insurance or workers’
compensation selfinsurance, fill with 0’s if
you do not have or
maintain a specific
number reference.

52

Policy Number

30

1001

1030

Alphanumeric

53

Claim Number

30

1031

1060

Alphanumeric

54

Plan Contact
Department
Name

70

1061

1130

Alphanumeric

55

Plan Contact Last
Name

40

1131

1170

Alphanumeric

Required.
The unique claim identifier
by which the primary plan
identifies the claim. If
liability self-insurance or
workers’ compensation
self-insurance, fill with 0’s
if you do not have or
maintain a claim number
reference.
Required.
Name of department for
the Plan Contact to which
claim-related
communication and
correspondence should be
sent.
Optional.
Surname of individual that
should be contacted at the
Plan for claim-related
communication and
correspondence.
Optional.

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34

Field
No.

Name

Size

Start
Pos.

End
Pos.

Data
Type

56

Plan Contact First
Name

30

1171

1200

Alphanumeric

57

Plan Contact
Phone

10

1201

1210

Numeric

Description

Given or first name of
individual that should be
contacted at the Plan for
claim-related
communication and
correspondence.
Optional.
Telephone number of
individual that should be
contacted at the Plan for
claim-related
communication.
Format with 3-digit area
code followed by 7-digit
phone number with no
dashes or other
punctuation (e.g.
1112223333).

58

Plan Contact
Phone Extension

5

1211

1215

Alphanumeric

Optional.
Telephone extension
number of individual that
should be contacted at the
Plan for claim-related
communication.

Fill with all spaces if
unknown or not
applicable.
Optional

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35

Field
No.
59

Name

No-Fault
Insurance Limit

Size

Start
Pos.

End
Pos.

Data
Type

11

1216

1226

Numeric

Description

Dollar amount of limit on
no-fault insurance.
Specify dollars and cents
with implied decimal. No
formatting (no $ or , or .)
For example, a limit of
$10,500.00 should be
coded as 00001050000.
Fill with all 9’s if there is
no dollar limit.
Fill with all 0’s if Plan
Insurance Type (Field 49)
is E (Workers’
Compensation) or L
(Liability Insurance).

60

Exhaust Date for
Dollar Limit for
No-Fault
Insurance

8

1227

1234

Numeric
Date

Required if Insurance
Plan Type (Field 49) is D
(No-Fault).
Date on which limit was
reached or benefits
exhausted for No-Fault
Insurance Limit (Field 59).
Format: CCYYMMDD
Fill with zeros if No-Fault
limit has not been
reached/exhausted or
Insurance Plan Type
(Field 49) is E (Workers’
Compensation) or L
(Liability insurance).
Required if Insurance
Plan Type (Field 49) is D
(No-Fault) and benefit
limit reached/exhausted.

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Field
No.

Name

Size

Start
Pos.

End
Pos.

Data
Type

Description

61

Reserved for
20 1235 1254
AlphaFill with spaces
Future Use
numeric
Injured Party’s Attorney or Other Representative Information
Attorney/Representative information required only if injured party has a representative.
62

Injured Party
Representative
Indicator

1

1255

1255

Alphanumeric

Code indicating the type
of Attorney/Other
Representative
information provided.
Valid values:
A = Attorney
G = Guardian/Conservator
P = Power of Attorney
O = Other
Space = None

63

64

Representative
Last Name

Representative
First Name

40

30

1256

1296

1295

1325

Alphabetic

Required if Injured Party
has a representative.
Surname of
representative.

Alphabetic

Required if Injured Party
has a representative.
Given or first name of
representative.
Required if Injured Party
has a representative.

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Field
No.
65

66

67

Name

Representative
Firm Name

Representative
TIN

Representative
Mailing Address
Line 1

Size

Start
Pos.

End
Pos.

Data
Type

70

1326

1395

Alphanumeric

9

50

1396

1405

1404

1454

Numeric

Description

Representative’s firm
name.
Required on reports
submitted on or after
January 1, 2011, if
Representative is
associated with or a
member of a firm.
Representative’s Federal
Tax Identification Number
(TIN). If representative is
part of a firm, supply the
firm’s Employer
Identification Number
(EIN), otherwise supply
the representative’s Social
Security Number (SSN).

Alphanumeric

Required if Injured Party
has a representative.
First line of the mailing
address for the
representative named
above.
Required if Injured Party
has a representative.
Second line of the mailing
address of the
representative named
above.

68

Representative
Mailing Address
Line 2

50

1455

1504

Alphanumeric

69

Representative
City

30

1505

1534

Alphanumeric

Mailing address city for
the representative named
above.
Required if Injured Party
has a representative.

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Field
No.
70

71

72

73

Name

Representative
State

Representative
Mail Zip Code

Representative
Mail Zip+4

Representative
Phone

Size

Start
Pos.

End
Pos.

Data
Type

2

1535

1536

Alphanumeric

5

4

10

1537

1542

1546

1541

1545

1555

Description

US Postal abbreviation
state code for the
representative named
above.

Numeric

Required if Injured Party
has a representative.
5-digit Zip Code for the
representative named
above.

Numeric

Required if Injured Party
has a representative.
4-digit Zip+4 code for the
representative named
above.

Numeric

If not applicable or
unknown, fill with zeroes
(0000).
Telephone number of the
representative named
above.
Format with 3-digit area
code followed by 7-digit
phone number with no
dashes or other
punctuation (e.g.
1112223333).

74

75

Representative
Phone Extension

Reserved for
Future Use

5

20

MMSEA111NGHPFileLayoutsInterim20081205

1556

1561

1560

1580

39

Alphanumeric

Alphanumeric

Required if Injured Party
has a representative.
Telephone extension
number of representative
named above.

Fill with all spaces if
unknown or not
applicable.
Fill with spaces.

Field
No.

76

Name

Size

Start
Pos.

End
Pos.

Data
Type

Description

Settlement, Judgment, Award or Other Payment Information
ORM Indicator
1 1581 1581
AlphaIndication of whether there
numeric is on-going responsibility
for medicals (ORM). Fill
with Y if there is ongoing
responsibility for medicals.
Valid values:
Y - Yes
N – No

77

ORM Termination
Date

8

1582

1589

Numeric
Date

Required.
Date on-going
responsibility for medicals
ended, where applicable.
Only applies to claims
submitted with ORM
Indicator = Y.
ORM Termination Date is
not applicable if claimant
retains the ability to
submit/apply for payment
for additional medicals
related to the claim.
Format: CCYYMMDD
Fill with zeroes if not
applicable.

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Field
No.
78

Name

Size

Start
Pos.

End
Pos.

Data
Type

Description

TPOC Date

8

1590

1597

Numeric
Date

Initial date of Total
Payment Obligation to the
Claimant (TPOC) without
regard to ongoing
responsibility for medical
services.
Date 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
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.
Format: CCYYMMDD
Not required for the
initial report of a claim
reflecting ongoing
payment responsibility.
If ongoing payment
responsibility ends due
to a settlement, report
the settlement date on
the second (final) report
for the ongoing case.
Otherwise fill with all
zeroes.
Required for all other
claim reports.

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Field
No.
79

Name

TPOC Amount

Size

Start
Pos.

End
Pos.

Data
Type

Description

11

1598

1608

Numeric

Total Payment Obligation
to the Claimant (TPOC)
amount: Dollar amount of
the total payment
obligation to the claimant.
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.
When reporting claims
reflecting ongoing
payment responsibility, fill
with zeroes unless the
ongoing responsibility
ended due to a
settlement.

80

Funding Delayed
Beyond TPOC
Start Date

8

1609

1616

Numeric
Date

Specify dollars and cents
with implied decimal. No
formatting (no $ , . ) For
example, an amount of
$10,500.55 should be
coded as 00001050055.
Required.
If funding for the Total
Payment Obligation to
Claimant is delayed,
provide actual or
estimated date of funding.
Format: CCYYMMDD
Fill with zeroes if not
applicable.

81

Reserved for
Future Use

20

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1617

1636

42

Alphanumeric

Fill with spaces

Field
No.

Name

Size

Start
Pos.

End
Pos.

Data
Type

Description

Claimant Information 1
This section is only required if the Claimant is not the Injured Party/Medicare Beneficiary.
The claimant may be the beneficiary’s estate, or other claimant in the case of wrongful
death or survivor action. Additional claimants must be listed on the Auxiliary Record. Fill
the entire section (Fields 82-95) with spaces if not supplying Claimant 1 information.
(This section is not used when the injured party/Medicare beneficiary is alive and an
individual is pursuing a claim on behalf of the beneficiary. See the section for Injured
Party’s Attorney or Other Representative Information.)
82

Claimant 1
Relationship

1

1637

1637

Alphanumeric

Relationship of the
claimant to the injured
party/Medicare
beneficiary.
Valid values:
E = Estate
F = Family
O = Other
Space = Not applicable
(rest of the section will be
ignored)
Optional July 1, 2009 –
March 31, 2010.

83

Claimant 1 TIN

9

1638

1646

Numeric

Required April 1, 2010
and subsequent if
claimant is not the
injured party.
Federal Tax Identification
Number (TIN), Employer
Identification Number
(EIN) or Social Security
Number (SSN) of
Claimant 1.
Must not match injured
party named above or
other claimant(s) listed on
the Auxiliary Record.
Required if claimant is
not the injured party.

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Field
No.
84

85

86
87

Name

Claimant 1 Last
Name

Claimant 1 First
Name

Claimant 1 Middle
Initial
Claimant 1
Mailing Address
Line 1

Size

Start
Pos.

End
Pos.

Data
Type

40

1647

1686

Alphabetic

30

1687

1716

1

1717

1717

50

1718

1767

Alphabetic

Alphabetic
Alphanumeric

88

Claimant 1
Mailing Address
Line 2

50

1768

1817

Alphanumeric

89

Claimant City

30

1818

1847

Alphabetic

90

91

Claimant 1 State

Claimant 1 Zip

2

5

1848

1850

1849

1854

Alphabetic

Numeric

Description

Surname of Claimant 1.
Required if claimant is
not the injured party.
Given/First name of
Claimant 1.
Required if claimant is
not the injured party.
First letter of Claimant 1’s
middle name.
First line of the mailing
address for the claimant
named above.
Required if claimant is
not the injured party.
Second line of the mailing
address of the claimant
named above.
Mailing address city for
the claimant named
above.
Required if claimant is
not the injured party.
US Postal abbreviation
state code for the claimant
named above.

Required if claimant is
not the injured party.
5-digit Zip Code for the
claimant named above.
Required if claimant is
not the injured party.

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Field
No.

Name

92

Claimant 1 Zip+4

93

Claimant 1 Phone

Size

Start
Pos.

End
Pos.

Data
Type

4

1855

1858

Numeric

10

1859

1868

Numeric

Description

4-digit Zip+4 code for the
claimant named above.
If not applicable or
unknown, fill with zeroes
(0000).
Telephone number of the
claimant named above.
Format with 3-digit area
code followed by 7-digit
phone number with no
dashes or other
punctuation (e.g.
1112223333).

94

95

Claimant 1 Phone
Extension

Reserved for
Future Use

5

20

MMSEA111NGHPFileLayoutsInterim20081205

1869

1874

1873

1893

45

Alphanumeric

Alphanumeric

Required if claimant is
not the injured party.
Telephone extension
number of the claimant
named above.
Fill with all spaces if
unknown or not
applicable.
Fill with spaces.

Field
No.

Name

Size

Start
Pos.

End
Pos.

Data
Type

Description

Claimant 1 Attorney/Other Representative Information
This section is only required if Claimant 1 has a representative. Fill the entire section
(Fields 96-109) with spaces if not supplying Claimant 1 representative information.
96

Claimant 1 (C1)
Representative
Indicator

1

1894

1894

Alphanumeric

Code indicating the type
of Attorney/Other
Representative
information provided for
Claimant 1.
Valid values:
A = Attorney
G = Guardian/Conservator
P = Power of Attorney
O = Other
Space = Not applicable
(rest of the section will be
ignored)

97

98

99

C1
Representative
Last Name

C1
Representative
First Name

C1
Representative
Firm Name

40

30

70

1895

1935

1965

1934

1964

2034

Alphabetic

Required if Claimant 1
has a representative.
Surname of C1
representative.

Alphabetic

Required if Claimant 1
has a representative.
Given/First name of C1
representative.

Alphanumeric

Required if Claimant 1
has a representative.
Representative’s firm
name.
Required on reports
submitted on or after
January 1, 2011, if
Representative is
associated with or a
member of a firm.

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Field
No.

Name

Size

Start
Pos.

End
Pos.

Data
Type

Description

C1 Representative’s
Federal Tax Identification
Number (TIN). If
representative is part of a
firm, supply the firm’s
Employer Identification
Number (EIN), otherwise
supply the
representative’s Social
Security Number (SSN).

100

C1
Representative
TIN

9

2035

2043

Numeric

101

C1
Representative
Mail Address 1

50

2044

2093

Alphanumeric

102

C1
Representative
Mailing Address 2

50

2094

2143

Alphanumeric

103

C1
Representative
Mailing City

30

2144

2173

Alphabetic

104

105

C1
Representative
State

C1
Representative
Zip

2

5

2174

2176

2175

2180

Alphabetic

Numeric

Required.
First line of the mailing
address for the C1
representative named
above.
Required if Claimant 1
has a representative.
Second line of the mailing
address of the C1
representative named
above.
Mailing address city for
the C1 representative
named above.
Required if Claimant 1
has a representative.
US Postal abbreviation
state code for the C1
representative named
above.
Required if Claimant 1
has a representative.
5-digit Zip Code for the C1
representative named
above.
Required if Claimant 1
has a representative.

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Field
No.
106

107

Name

C1
Representative
Zip+4

C1
Representative
Phone

Size

Start
Pos.

End
Pos.

Data
Type

Description

4

2181

2184

Numeric

4-digit Zip+4 code for the
C1 representative named
above.

10

2185

2194

Numeric

If not applicable or
unknown, fill with zeroes
(0000).
Telephone number of the
C1 representative named
above.
Format with 3-digit area
code followed by 7-digit
phone number with no
dashes or other
punctuation (e.g.
1112223333).

108

109

C1
Representative
Phone Extension

Reserved for
Future Use

5

21

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2195

2200

2199

2220

48

Alphanumeric

Alphanumeric

Required if Claimant 1
has a representative.
Telephone extension
number of the C1
representative named
above.
Fill with all spaces if
unknown or not
applicable.
Fill with spaces.

MMSEA Section 111
Liability Insurance (Including Self-Insurance), No-Fault Insurance, Workers’
Compensation Input Claim File Auxiliary Record – 2220 bytes

This record is only required if there are additional claimants to report for the
associated Detail Claim Record. Do not include this record for the claim if there are
no additional claimants to report. Claimant 1 on the Detail Claim Record must be
completed in order for information concerning additional claimants to be accepted.

Field
No.

Name

1

Record Identifier

2

DCN

Size

Start
Pos.

End
Pos.

4

1

4

15

5

19

Data
Type

Description

Alphanumeric
Alphanumeric

Must be 'NGCE'.
Required.
Document Control Number
(DCN) assigned by the
Section 111 RRE.
Must match the DCN on
the corresponding Detail
Claim Record (Record
Identifier NGCD).

3

Injured Party HICN

12

20

31

Alphanumeric

4

Injured Party SSN

9

32

40

Numeric

5

6

Injured Party Last
Name

Injured Party First
Name

40

30

41

81

80

110

Required.
Must match the value in
this field on the Detail
Claim Record.
Required.
Must match the value in
this field on the Detail
Claim Record.

Alphabetic

Required.
Must match the value in
this field on the Detail
Claim Record.

Alphabetic

Required.
Must match the value in
this field on the Detail
Claim Record.
Required.

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Field
No.

Name

Size

Start
Pos.

End
Pos.

Data
Type

Description

Claimant 2 Information
7

Claimant 2
Relationship

1

111

111

Alphanumeric

Relationship of the
claimant to the injured
party/Medicare
beneficiary.
Valid values:
E = Estate
F = Family
O = Other
Space = Not applicable
(rest of the section will be
ignored)

8

Claimant 2 TIN

9

112

120

Numeric

Required on reports
April 1, 2010 and
subsequent.
Federal Tax Identification
Number (TIN), Employer
Identification Number
(EIN) or Social Security
Number (SSN) of Claimant
2.
Must not match injured
party named above or
other claimant(s) listed on
the Auxiliary Record.

9

Claimant 2 Last
Name

10

Claimant 2 First
Name

11

Claimant 2 Middle
Initial

40

121

160

Alphabetic

Required.
Surname of Claimant 2.

30

161

190

Alphabetic

Required.
Given/First name of
Claimant 2.

1

191

191

Alphabetic

Required.
First letter of Claimant 2’s
middle name.

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Field
No.

Name

Size

Start
Pos.

End
Pos.

Data
Type

Description

12

Claimant 2
Mailing Address
Line 1

50

192

241

Alphanumeric

13

Claimant 2
Mailing Address
Line 2

50

242

291

Alphabetic

Required.
Second line of the mailing
address for Claimant 2
named above.

14

Claimant 2 City

30

292

321

Alphabetic

Mailing address city for
Claimant 2 named above.

15

Claimant 2 State

2

322

323

Alphabetic

Required.
US Postal abbreviation
state code for Claimant 2
named above.

16

Claimant 2 Zip

5

324

328

Numeric

Required.
5-digit Zip Code for
Claimant 2 named above.

Numeric

Required.
4-digit Zip+4 code for
Claimant 2 named above.

17

18

Claimant 2 Zip+4

Claimant 2 Phone

4

10

329

333

332

342

Numeric

First line of the mailing
address for Claimant 2
named above.

If not applicable or
unknown, fill with zeroes
(0000).
Telephone number of
Claimant 2 named above.
Format with 3-digit area
code followed by 7-digit
phone number with no
dashes or other
punctuation (e.g.
1112223333).
Required.

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Field
No.

Name

19

Claimant 2 Phone
Extension

20

Reserved for
Future Use

Size

Start
Pos.

End
Pos.

5

343

347

20

348

367

Data
Type
Alphanumeric

Alphanumeric

Description

Telephone extension
number of Claimant 2
named above.
Fill with all spaces if
unknown or not applicable.
Fill with spaces.

Claimant 2 Attorney/Other Representative Information
This section is only required if Claimant 2 has a representative. Fill the entire section
(Field 21-34) with spaces if not supplying Claimant 2 representative information.
1
368
368
AlphaCode indicating the type of
21
Claimant 2 (C2)
numeric Attorney/Other
Representative
Representative information
Indicator
provided for Claimant 2
(C2).
Valid values:
A = Attorney
G = Guardian/Conservator
P = Power of Attorney
O = Other
Space = Not applicable
(rest of the section will be
ignored)

22

23

C2
Representative
Last Name

C2
Representative
First Name

40

30

369

409

408

438

Alphabetic

Required if Claimant 2
has a representative.
Surname of C2 attorney or
representative.

Alphabetic

Required if Claimant 2
has a representative.
Given/First name of C2
attorney or representative.
Required if Claimant 2
has a representative.

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Field
No.
24

Name

C2
Representative
Firm Name

Size

Start
Pos.

End
Pos.

70

439

508

Data
Type
Alphanumeric

25

C2
Representative
TIN

9

509

517

Numeric

26

C2
Representative
Mailing Address
Line 1

50

518

567

Alphanumeric

27

28

29

C2
Representative
Mailing Address
Line 2
C2
Representative
City

C2
Representative
State

50

568

617

Alphanumeric

30

618

647

Alphabetic

2

648

649

Alphabetic

Description

Representative’s firm
name.
Required on reports
submitted on or after
January 1, 2011, if
Representative is
associated with or a
member of a firm.
C2 Representative’s
Federal Tax Identification
Number (TIN). If
representative is part of a
firm, supply the firm’s
Employer Identification
Number (EIN), otherwise
supply the representative’s
Social Security Number
(SSN).
Required.
First line of the mailing
address for the C2
representative named
above.
Required if Claimant 2
has a representative.
Second line of the mailing
address of the C2
representative named
above.
Mailing address city for the
C2 representative named
above.
Required if Claimant 2
has a representative.
US Postal abbreviation
state code for the C2
representative named
above.
Required if Claimant 2
has a representative.

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Field
No.
30

31

32

Name

C2
Representative
Zip

C2
Representative
Zip+4

C2
Representative
Phone

Size

Start
Pos.

End
Pos.

5

650

654

4

10

655

659

658

668

Data
Type

Description

Numeric

5-digit Zip Code for the C2
representative named
above.

Numeric

Numeric

Required if Claimant 2
has a representative.
4-digit Zip+4 code for the
C2 representative named
above.
If not applicable or
unknown, fill with zeroes
(0000).
Telephone number of the
C2 representative named
above.
Format with 3-digit area
code followed by 7-digit
phone number with no
dashes or other
punctuation (e.g.
1112223333).

33

34

C2
Representative
Phone Extension

Reserved for
Future Use

5

20

MMSEA111NGHPFileLayoutsInterim20081205

669

674

673

693

54

Alphanumeric

Alphanumeric

Required if Claimant 2
has a representative.
Telephone extension
number of the C2
representative named
above.
Fill with all spaces if
unknown or not applicable.
Fill with spaces.

Field
No.

Name

Size

Start
Pos.

End
Pos.

Data
Type

Description

Claimant 3 Information

Fill entire section with spaces if not applicable. See Claimant 2 Information section
above for individual field specifications.

35

Claimant 3
Relationship

1

694

694

Alphanumeric

Relationship of the
claimant to the injured
party/Medicare
beneficiary.
Valid values:
E = Estate
F = Family
O = Other
Space = Not applicable
(rest of the section will be
ignored)

36

Claimant 3 TIN

37

42

Claimant 3 Last
Name
Claimant 3 First
Name
Claimant 3 Middle
Initial
Claimant 3
Mailing Address
Line 1
Claimant 3
Mailing Address
Line 2
Claimant 3 City

43
44
45

38
39
40

41

9

695

703

Numeric

40

704

743

30

744

773

1

774

774

50

775

824

Alphabetic
Alphabetic
Alphabetic
Alphanumeric

50

825

874

Alphanumeric

30

875

904

Claimant 3 State

2

905

906

Claimant 3 Zip
Claimant 3 Zip+4

5
4

907
912

911
915

Alphabetic
Alphabetic
Numeric
Numeric

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55

Field
No.

Name

46

Claimant 3 Phone

47

Claimant 3 Phone
5
926
930
AlphaExtension
numeric
Reserved for
20
931
950
AlphaFill with spaces.
Future Use
numeric
Claimant 3 Attorney/Representative Information

48

Size

Start
Pos.

End
Pos.

10

916

925

Data
Type

Description

Numeric

This section is only required if Claimant 3 has a representative. Fill the entire section
(Field 49-62) with spaces if not supplying Claimant 3 representative information. See
corresponding Claimant 2 Attorney/Representative Information section for
individual field specifications.
49

Claimant 3 (C3)
Representative
Indicator

1

951

951

Alphanumeric

50

C3
Representative
Last Name
C3
Representative
First Name
C3
Representative
Firm Name
C3
Representative
TIN
C3
Representative
Mailing Address
Line 1
C3
Representative
Mailing Address
Line 2
C3
Representative
City

40

952

991

Alphabetic

30

992

1021

Alphabetic

70

1022

1091

Alphanumeric

9

1092

1100

Numeric

50

1101

1150

Alphanumeric

50

1151

1200

Alphanumeric

30

1201

1230

Alphabetic

51

52

53

54

55

56

MMSEA111NGHPFileLayoutsInterim20081205

56

Field
No.

Name

57

C3
Representative
State
C3
Representative
Zip
C3
Representative
Zip+4
C3
Representative
Phone
C3
Representative
Phone Extension
Reserved for
Future Use

58

59

60

61

62

Size

Start
Pos.

End
Pos.

Data
Type

2

1231

1232

Alphabetic

5

1233

1237

Numeric

4

1238

1241

Numeric

10

1242

1251

Numeric

5

1252

1256

Alphanumeric

20

1257

1276

Alphanumeric
Claimant 4 Information

Description

Fill with spaces.

Fill entire section with spaces if not applicable. See Claimant 2 Information section
above for individual field specifications.
63

Claimant 4
Relationship

1

1277

1277

Alphanumeric

64

Claimant 4 TIN

9

1278

1286

Numeric

65

Claimant 4 Last
Name
Claimant 4 First
Name
Claimant 4 Middle
Initial
Claimant 4
Mailing Address
Line 1
Claimant 4
Mailing Address
Line 2
Claimant 4 City

40

1287

1326

30

1327

1356

1

1357

1357

50

1358

1407

Alphabetic
Alphabetic
Alphabetic
Alphanumeric

50

1408

1457

Alphanumeric

30

1458

1487

Alphabetic

66
67
68

69

70

MMSEA111NGHPFileLayoutsInterim20081205

57

Field
No.

Name

Size

Start
Pos.

End
Pos.

Data
Type
Alphabetic
Numeric
Numeric
Numeric

71

Claimant 4 State

2

1488

1489

72
73
74

Claimant 4 Zip
Claimant 4 Zip+4
Claimant 4 Phone

5
4
10

1490
1495
1499

1494
1498
1508

75

Description

Claimant 4 Phone
5 1509 1513
AlphaExtension
numeric
76
Reserved for
20 1514 1533
AlphaFill with spaces.
Future Use
numeric
Claimant 4 Attorney/Representative Information
This section is only required if Claimant 4 has a representative. Fill the entire section
(Field 77-90) with spaces if not supplying Claimant 4 representative information. See
corresponding Claimant 2 Attorney/Representative Information section for
individual field specifications.
77
Claimant 4 (C4)
1 1534 1534
AlphaRepresentative
betic
Indicator
40 1535 1574
Alpha78
C4
betic
Representative
Last Name
79
C4
30 1575 1604
AlphaRepresentative
betic
First Name
80
C4
70 1605 1674
AlphaRepresentative
numeric
Firm Name
81
C4
9 1675 1683 Numeric
Representative
TIN
50 1684 1733
Alpha82
C4
numeric
Representative
Mailing Address
Line 1
83
C4
50 1734 1783
AlphaRepresentative
numeric
Mailing Address
Line 2
84
C4
30 1784 1813
AlphaRepresentative
betic
City
2 1814 1815
Alpha85
C4
betic
Representative
State

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58

Field
No.

Name

86

C4
Representative
Zip
C4
Representative
Zip+4
C4
Representative
Phone
C4
Representative
Phone Extension
Reserved for
Future Use

87

88

89

90

Size

Start
Pos.

End
Pos.

Data
Type

5

1816

1820

Numeric

4

1821

1824

Numeric

10

1825

1834

Numeric

5

1835

1839

Alphanumeric

381

1840

2220

Alphanumeric

MMSEA111NGHPFileLayoutsInterim20081205

59

Description

Fill with spaces.

MMSEA Section 111
Liability Insurance (Including Self-Insurance), No-Fault Insurance, Workers’
Compensation Input Claim File Trailer Record – 2220 bytes
Field
No.

Name

Len

Start
Pos.

End
Pos.

1

Record
Identifier

4

1

4

2

Section 111
Reporter ID

9

5

13

3

Section 111
Reporting
File Type
File
Submission
Date

7

14

20

8

21

28

4

Type

Alphanumeric

Description

Must be ‘NGCT’

Required.
Numeric COBC assigned Section
111Reporter ID #.

Alphanumeric

Required.
Must be ‘NGHPCLM’

Required.
Numeric Date file was transmitted to the
Date
COBC.
Format: CCYYMMDD

5

File Record
Count

6

Reserved for
Future Use

7

2185

29

35

36 2220

MMSEA111NGHPFileLayoutsInterim20081205

Required.
Numeric Number of records contained
within file (do not include header
or trailer records in the count)

Alphanumeric

60

Required.
Fill with spaces.

MMSEA Section 111 Mandatory Reporting - Liability
Insurance (Including Self-Insurance), No-Fault
Insurance, Workers’ Compensation
TIN Reference File Layout – to be submitted with the
Input Claim File

MMSEA Section 111
Liability Insurance (Including Self-Insurance), No-Fault Insurance, Workers’
Compensation TIN Reference File Header Record – 2220 bytes

Field
No.

Name

Size

Start
Pos.

End
Pos.

Data
Type

Description

1

Record
Identifier

4

1

4

Alphanumeric

2

Section 111
Reporter ID

9

5

13

Alphanumeric

3

Section 111
Reporting
File Type
File
Submission
Date

7

14

20

Alphanumeric

21

Required.
28 Numeric Date file was transmitted to the
Date
COBC.

4

8

Must be ‘NGTH’
Required.
COBC assigned Section
111Reporter ID #.
Required.
Must be ‘NGHPTIN’

Format: CCYYMMDD

5

Reserved for
Future Use

2192

29 2220

MMSEA111NGHPFileLayoutsInterim20081205

Alphanumeric

61

Required.
Fill with spaces.

MMSEA Section 111
Liability Insurance (Including Self-Insurance) No-Fault Insurance, Workers’
Compensation TIN Reference File Detail TIN/Site ID Record – 2220 bytes

Field
No.

Name

Size

Start
Pos.

End
Pos.

1

Record Identifier

4

1

4

2

Section 111
Reporter ID

9

5

3

TIN

9

14

Data
Type

Alphanumeric

13 Numeric

22

Numeric

Description

Must be ‘NGTD’
Required.
COBC assigned Section
111Reporter ID #.
Required.
Federal Tax Identification
Number of the insurer,
applicable plan (s),
workers’ compensation
law/plan (s), or self-insured
entities reported in Field 49
of each Detail Claim
Record. Used in
conjunction with the Site ID
reported in Field 50 of the
Detail Claim Record.
Also know as the Employer
Identification Number (EIN).
Each TIN/Site ID
combination reported in
Fields 49 and 50 of the
Detail Claim Records must
have a corresponding
record reported on the TIN
Reference File. A record
must be submitted on the
TIN Reference File for each
unique TIN/Site ID
combination.
Required.

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Field
No.
4

Name

Office Code/Site
ID

Size Start
Pos.
9

23

End
Pos.
31

Data
Type
AlphaNumeric

Description

RRE-defined code to
uniquely identify variations
in insurer addresses/claim
offices/Plan Contact
Addresses as reported in
Field 50 of each Detail
claim Record. Used in
conjunction with the TIN
reported in Field 49 of the
Detail Claim record to
uniquely specify different
addresses associated with
one TIN.
If only one address will be
used per reported TIN,
leave blank.
Each TIN/Site ID
combination reported in
Fields 49 and 50 of the
Detail Claim Records must
have a corresponding
record reported on the TIN
Reference File. A record
must be submitted on the
TIN Reference File for each
unique TIN/Site ID
combination.

5

TIN/Site ID
Mailing Name

70

32

101

Alphanumeric

Required.
Name associated with the
RRE reflected by the
unique TIN/Site ID
combination.
Required.

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Field
No.
6

Name

TIN/Site ID
Mailing Address
Line 1

Size Start
Pos.
50

102

End
Pos.
151

Data
Type

Description

Alphanumeric

First line of the address
associated with the unique
TIN/Site ID combination
reflected on this record.
This mailing address
should reflect where the
RRE wishes to have the
recoveries and other
associated correspondence
directed for the TIN/Site ID
combination.

7

TIN/Site ID
Mailing Address
Line 2

50

152

201

Alphanumeric

Required.
Second line of the address
associated with the unique
TIN/Site ID combination
reflected on this record.
This mailing address
should reflect where the
RRE wishes to have the
recoveries and other
associated correspondence
directed for the TIN/Site ID
combination.

8

TIN/Site/ID City

30

202

231

Alphanumeric

City of the address
associated with the unique
TIN/Site ID combination
reflected on this record.
This mailing address
should reflect where the
RRE wishes to have the
recoveries and other
associated correspondence
directed for the TIN/Site ID
combination.
Required.

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Field
No.

Name

9

TIN/Site ID State

Size

Start
Pos.

End
Pos.

2

232

233

Data
Type

Description

Alphanumeric

US Postal state
abbreviation of the address
associated with the unique
TIN/Site ID combination
reflected on this record.
This mailing address
should reflect where the
RRE wishes to have the
recoveries and other
associated correspondence
directed for the TIN/Site ID
combination.

10

TIN/Site ID Zip

5

234

238

Numeric

11

TIN/Site ID
Zip+4

4

239

242

Numeric

12

Reserved for
Future Use

1978

243

MMSEA111NGHPFileLayoutsInterim20081205

2220

65

Alphanumeric

Required.
5-digit Zip Code of the
address associated with the
unique TIN/Site ID
combination reflected on
this record.
Required.
4-digit Zip+4 code of the
address associated with the
unique TIN/Site ID
combination reflected on
this record.
If not applicable fill with
zeroes (0000).
Fill with spaces.

MMSEA Section 111
Liability Insurance (Including Self-Insurance), No-Fault Insurance, Workers’
Compensation TIN Reference File Trailer Record – 2220 bytes

Field
No.

Name

Size

Start
Pos.

End
Pos.

1

Record
Identifier

4

1

4

2

Section 111
Reporter ID

9

5

13

3

4

Section 111
Reporting
File Type
File
Submission
Date

Date
Type

Alphanumeric

Description

Must be ‘NGTT’

Required.
Numeric COBC assigned Section
111Reporter ID #.

7

14

20

Alphanumeric

8

21

28

Numeric
Date

Required.
Must be ‘NGHPTIN’
Required.
Date file was transmitted to the
COBC.
Format: CCYYMMDD

5

6

File Record
Count

Reserved for
Future Use

7

2185

29

35

36 2220

MMSEA111NGHPFileLayoutsInterim20081205

Numeric

Alphanumeric

66

Required.
Number of records contained
within this TIN Reference File
(do not include header or trailer
records in count)
Required.
Fill with spaces.

MMSEA Section 111 Mandatory Reporting - Liability
Insurance (Including Self-Insurance), No-Fault
Insurance, Workers’ Compensation
Claim Response File Layout

MMSEA Section 111
Liability Insurance (Including Self-Insurance), No-Fault Insurance, Workers’
Compensation Claim Response File Header Record – 400 bytes

Field
No.

Name

Size Start End
Pos. Pos.

Record
Identifier

4

1

2

Section 111
Reporter ID

9

5

3

Section 111
Reporting
File Type
File
Submission
Date

7

14

20

21

COBC supplied.
28 Numeric Date file was transmitted to the
Date
RRE.

8

Alphanumeric

Description

1

4

4

Data
Type

Contains value of ‘NGRH’

COBC supplied.
13 Numeric COBC assigned Section
111Reporter ID #.

Alphanumeric

As supplied by RRE input record.
Contains value of ‘NGHPRSP’

Format: CCYYMMDD

5

Reserved
for Future
Use

372

29

MMSEA111NGHPFileLayoutsInterim20081205

400

Alphanumeric

67

COBC supplied.
Contains all spaces.

MMSEA Section 111
Liability Insurance (Including Self-Insurance), No-Fault Insurance, Workers’
Compensation Claim Response File Detail Record – 400 bytes

Field
No.

Name

1

Record
Identifier

2

Submitted
DCN

3

4

5

6

7

8

9

Submitted
Action Type

Injured Party
HICN

Submitted
Injured Party
SSN

Submitted
Injured Party
Last Name
Submitted
Injured Party
First Name
Submitted
Injured Party
Middle Init
Submitted
Injured Party
Gender

Size Start End
Pos. Pos.

Data
Type

4

1

4

Alphanumeric

15

5

19

Alphanumeric

1

12

9

20

21

33

Description

Contains value of 'NGRD'
COBC supplied.
Document Control Number
(DCN) submitted by RRE on
input record. Used for matching
input records with response
records.

As supplied by RRE on input
record.
20 Numeric Action to be performed.

32

Alphanumeric

As supplied by RRE on input
record.
Health Insurance Claim Number
(HICN) of Injured Party.

As supplied by RRE on input
record.
41 Numeric Social Security Number of
Injured Party.

40

42

81

Alphabetic

As supplied by RRE on input
record.
As supplied by RRE on input
record.

30

82

111

Alphabetic

As supplied by RRE on input
record.

1

112

112

Alphabetic

As supplied by RRE on input
record.

1

113

113 Numeric As supplied by RRE on input
record.

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68

Field
No.
10

11
12

13
14

Name

Submitted
Injured Party
DOB
Submitted
Plan TIN
Submitted
Plan Office
Code/Site ID
Reserved for
Future Use
Applied
Injured Party
HICN

Size

Start
Pos.

End
Pos.

Data
Type

Description

8

114

121

Numeric
Date

As supplied by RRE on input
record.

9

122

130

Numeric

9

131

139

AlphaNumeric

As supplied by RRE on input
record.
As supplied by RRE on input
record.

20

140

159

12

160

171

Alphanumeric
Alphanumeric

Filled with spaces.
Current Medicare Health
Insurance Claim Number
(HICN) of Injured Party if
confirmed to be a Medicare
beneficiary.
COBC supplied.
Social Security Number
(SSN) of Injured Party if
confirmed to be a Medicare
beneficiary.

15

Applied
Injured Party
SSN

9

172

180

Numeric

16

Applied
Injured Party
Last Name

40

181

220

Alphabetic

COBC supplied.
Injured Party Last Name if
confirmed to be a Medicare
beneficiary.

17

Applied
Injured Party
First Name

30

221

250

Alphabetic

COBC supplied.
Injured Party First Name if
confirmed to be a Medicare
beneficiary.

Alphabetic

COBC supplied.
Injured Party Middle Initial if
confirmed to be a Medicare
beneficiary.

18

Applied
Injured Party
Middle Initial

1

251

251

COBC supplied.

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69

Field
No.
19

Name

Applied
Injured Party
Gender

Size

1

Start
Pos.
252

End
Pos.
252

Data
Type
Numeric

Description

Sex of Injured Party if
confirmed to be a Medicare
beneficiary.
COBC supplied.
1 - Male
2 - Female

20

Applied
Injured Party
DOB

8

253

260

Numeric
Date

Date of birth (DOB) of Injured
Party if confirmed to be a
Medicare beneficiary.
Format: CCYYMMDD

21

Applied MSP
Effective Date

8

261

268

Numeric
Date

COBC supplied.
Applied Medicare Secondary
Payer (MSP) effective date.
If injured party is found to be
a Medicare beneficiary, the
start date of Medicare’s
secondary payment status for
the incident, illness or injury.
Will be the later of the
beneficiary’s Medicare
entitlement/eligibility start date
or the CMS Date of Incident
(DOI). This is the effective
date of the MSP occurrence
posted to the Medicare
Common Working File (CWF)
which is used in Medicare
claim payment
determinations.
Format: CCYYMMDD
COBC supplied.

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70

Field
No.
22

Name

Applied MSP
Termination
Date

Size

8

Start
Pos.
269

End
Pos.
276

Data
Type
Numeric
Date

Description

Applied Medicare Secondary
Payment (MSP) Termination
Date.
If injured party is found to be
a Medicare beneficiary, the
end date of Medicare’s
secondary payment status for
the incident, illness or injury.
This is the end date of the
MSP occurrence posted to
the Medicare Common
Working File (CWF) which is
used in Medicare claim
payment determinations.
Format: CCYYMMDD
Will contain all zeroes if openended.

23

Applied MSP
Type Indicator

1

277

277

Alphanumeric

COBC supplied.
Applied Medicare Secondary
Payer (MSP) Type.
D = No-Fault
E = Workers’ Compensation
L = Liability

24
25

Reserved for
Future Use
Applied
Disposition
Code

20

278

297

2

298

299

Alphanumeric
Alphanumeric

COBC supplied.
Filled with spaces.
2-digit code indicating how
the record was processed.
Will indicate whether the
submitted record was in error
or whether Medicare is the
secondary payer.
See Disposition Code Table
for values.
COBC supplied.

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71

Field
No.

Name

Size

Start
Pos.

End
Pos.

Data
Type

Description

The following Error Code fields indicate an error was found on the submitted claim
record. The submitted claim record was rejected and not processed. The RRE must
correct these errors and resubmit the record on the next quarterly file submission.
26
Applied Error
5
300
304
AlphaCode associated with an error
Code 1
numeric found by the COBC in the
submitted record. Provided
only if disposition code
denotes error.
See Error Code Table for
values.

27

Applied Error
Code 2

5

305

309

Alphanumeric

28

Applied Error
Code 3

5

310

314

Alphanumeric

29

Applied Error
Code 4

5

315

319

Alphanumeric

COBC supplied.
Code associated with an error
found by the COBC in the
submitted record. Provided
only if disposition code
denotes error and at least 2
errors were found.
See Error Code Table for
values.
COBC supplied.
Code associated with an error
found by the COBC in the
submitted record. Provided
only if disposition code
denotes error and at least 3
errors were found.
See Error Code Table for
values.
COBC supplied.
Code associated with an error
found by the COBC in the
submitted record. Provided
only if disposition code
denotes error and at least 4
errors were found.
See Error Code Table for
values.
COBC supplied.

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72

Field
No.

Name

Size

Start
Pos.

End
Pos.

Data
Type

Description

Code associated with an error
found by the COBC in the
submitted record. Provided
only if disposition code
denotes error and at least 5
errors were found.
See Error Code Table for
values.

30

Applied Error
Code 5

5

320

324

Alphanumeric

31

Applied Error
Code 6

5

325

329

Alphanumeric

32

Applied Error
Code 7

5

330

334

Alphanumeric

COBC supplied.
Code associated with an error
found by the COBC in the
submitted record. Provided
only if disposition code
denotes error and at least 6
errors were found.
See Error Code Table for
values.
COBC supplied.
Code associated with an error
found by the COBC in the
submitted record. Provided
only if disposition code
denotes error and at least 7
errors were found.
See Error Code Table for
values.
COBC supplied.

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73

Field
No.

Name

Size

Start
Pos.

End
Pos.

Data
Type

Description

Code associated with an error
found by the COBC in the
submitted record. Provided
only if disposition code
denotes error and at least 8
errors were found.
See Error Code Table for
values.

33

Applied Error
Code 8

5

335

339

Alphanumeric

34

Applied Error
Code 9

5

340

344

Alphanumeric

35

Applied Error
Code 10

5

345

349

Alphanumeric

COBC supplied.
Code associated with an error
found by the COBC in the
submitted record. Provided
only if disposition code
denotes error and at least 9
errors were found.
See Error Code Table for
values.
COBC supplied.
Code associated with an error
found by the COBC in the
submitted record. Provided
only if disposition code
denotes error and at least 10
errors were found.
See Error Code Table for
values.
COBC supplied.

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74

Field
No.

Name

Size

Start
Pos.

End
Pos.

Data
Type

Description

The following Compliance Flag fields provide information on issues related to reporting
requirement compliance. Records will not be rejected for these issues. The
disposition code in Field 25 will indicate how the record was processed by the COBC.
The RRE must review and correct compliance issues as applicable and resubmit the
record as an update transaction on the next quarterly file submission.
36
Applied
2
350
351
AlphaAlphanumeric code indicating
Compliance
numeric compliance issue found with
Flag 1
record.
See Compliance Code Table
for values.
COBC supplied.
37
Applied
2
352
353
AlphaAlphanumeric code indicating
Compliance
numeric compliance issue found with
Flag 2
record. Populated if at least 2
issues were found.
See Compliance Code Table
for values.
COBC supplied.
38
Applied
2
354
355
AlphaAlphanumeric code indicating
Compliance
numeric compliance issue found with
Flag 3
record. Populated if at least 3
issues were found.
See Compliance Code Table
for values.
COBC supplied.
39
Applied
2
356
357
AlphaAlphanumeric code indicating
Compliance
numeric compliance issue found with
Flag 4
record. Populated if at least 4
issues were found.
See Compliance Code Table
for values.
COBC supplied.
40
Applied
2
358
359
AlphaAlphanumeric code indicating
Compliance
numeric compliance issue found with
Flag 5
record. Populated if at least 5
issues were found.
See Compliance Code Table
for values.
COBC supplied.

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75

Field
No.

Name

Size

Start
Pos.

End
Pos.

Data
Type

Description

Alphanumeric code indicating
compliance issue found with
record. Populated if at least 6
issues were found.
See Compliance Code Table
for values.
COBC supplied.
Alphanumeric code indicating
compliance issue found with
record. Populated if at least 7
issues were found.
See Compliance Code Table
for values.
COBC supplied.
Alphanumeric code indicating
compliance issue found with
record. Populated if at least 8
issues were found.
See Compliance Code Table
for values.
COBC supplied.
Alphanumeric code indicating
compliance issue found with
record. Populated if at least 9
issues were found.
See Compliance Code Table
for values.
COBC supplied.
Alphanumeric code indicating
compliance issue found with
record. Populated if 10 issues
were found.
See Compliance Code Table
for values.
COBC supplied.
Filled with spaces.

41

Applied
Compliance
Flag 6

2

360

361

Alphanumeric

42

Applied
Compliance
Flag 7

2

362

363

Alphanumeric

43

Applied
Compliance
Flag 8

2

364

365

Alphanumeric

44

Applied
Compliance
Flag 9

2

366

367

Alphanumeric

45

Applied
Compliance
Flag 10

2

368

369

Alphanumeric

46

Reserved for
Future Use

31

370

400

Alphanumeric

MMSEA111NGHPFileLayoutsInterim20081205

76

MMSEA Section 111
Liability Insurance (Including Self-Insurance), No-Fault Insurance, Workers’
Compensation Claim Response File Trailer Record – 400 bytes

Field
No.

Name

Size Start End
Pos. Pos.

Record
Identifier

4

1

2

Section 111
Reporter ID

9

5

3

Section 111
Reporting
File Type
File
Submission
Date

7

14

20

21

COBC supplied.
28 Numeric Date file was transmitted to the
Date
RRE.

8

Alphanumeric

Description

1

4

4

Data
Type

Contains value of ‘NGRT’

COBC supplied.
13 Numeric COBC assigned Section
111Reporter ID #.

Alphanumeric

As supplied by RRE input record.
Contains value of ‘NGHPRSP’

Format: CCYYMMDD

4

5

File Record
Count

Reserved
for Future
Use

7

365

29

36

MMSEA111NGHPFileLayoutsInterim20081205

COBC supplied.
35 Numeric Number of detail response
records contained within file (does
not include header or trailer
records).

400

Alphanumeric

77

COBC supplied.
Filled with spaces.