Case Information Screen Liability
Claimant Information
Fields marked with a red asterisk mark (*) are mandatory.
* Last Name

* First Name

* SSN (xxx-xx-xxxx)

* Date of Birth (mm/dd/yyyy)

*Gender
Street Address
City:
State
select
Zip
* Claim Number

* Date of Accident (mm/dd/yyyy)

*State of Jurisdiction
select

* Case Type





 
* Self-Insured
* Carrier

* TPA/Servicing Agent

Excess Carrier
 
Defendant Name

  Contact Information
  Defense Attorney
 Plaintiff/Claimant Attorney
 Structured Settlement Broker
*Service Requested: Please call 888.672.7674 with any questions.
To prevent delays or complications with completing the requested service please confirm the information reported to Medicare through Section 111 reflects what is being provided on the referral form for the requested service.  
MSA Compliance Solutions
Conditional Payment Compliance Solutions
Claim Forcasting Solutions
Clinical Cost Containment Solutions
MSA Funds Administration
Additional Information
  Notes:
(Please include any information related to this file not otherwise noted.
Maximum 5000 characters are allowed.)
 
   
Pertinent Information Related to the File:
* What diagnoses/body part(s) are accepted in this claim?  
What diagnoses/body part(s) are pre-existing/disputed in this claim?
What is the proposed settlement amount?  
Please note, CMS shares Section 111 reporting data with the Workers’ Compensation Review Center (WCRC), Benefits Coordination Recovery Center (BCRC), Commercial Repayment Center (CRC) and Medicare Advantage Plans (MAP) to aid in the recovery of conditional payments and the approval of the Medicare Set-Aside.  Optum encourages a review of the ICD codes, Ongoing Responsibility of Medical (ORM) and Total Payment Obligation to Claimant (TPOC) information provided through Section 111 mandatory insurer reporting, to ensure accurate reporting, as Medicare’s claims processing contractors will use this information to pay or deny medical bills accordingly.
“The CMS portal used to submit MSAs to the WCRC for approval does not accept a file that has both ICD-9 and ICD-10 codes. If this MSA is to be submitted to CMS for approval the codes will need to up updated to whatever codes have been provided through MMSEA Section 111 reporting (ICD-9 if pre 10/5/15 DOA or ICD-10 if post 10/5/15 DOA). To aid in the conversion Optum provides an ICD look up tool which can be accessed by clicking https://medicareconnect.pmsionline.com/.”
Unless otherwise indicated, the referring party will be responsible for all payments.
**Cancellation of LMSA or LFMA after work has commenced is subjected to a fee of $1,300.
If you would like an email confirmation, please enter your email address below. If you would like to send to multiple email addresses, please enter each address separated by a semi-colon. If you have already provided an email address in the Adjuster Contact Information section of this form, you will automatically receive an email confirmation.
Confirmation Email
Please indicate the Optum Settlement Solutions Associate that worked with you on this file: