ORM & TPOC Claim Information Form

* indicates a required field

Injured Party Information

HICN or SSN*
Last Name*
First Name*
Middle Initial
Gender*
Date of Birth*

Injury/Incident/Illness Information

CMS Date of Injury*	Date of the accident, date of first exposure, date of first ingestion, or date of the implant (first implant if there are multiples). If cumulative injury, whichever is earlier: the date that treatment began or the first date that formal diagnosis was made
State of Venue*	US State (including The District of Columbia, American Samoa, Guam, Puerto Rico, Washington DC and the US Virgin Islands) whose state law controls resolution of the claim. List US if claim is based on federal law.
ICD-9 or ICD-10 Diagnosis Codes* (no more than 19, must provide at least 1)	ICD-9-CM Diagnosis Code describing the alleged injury/illness. Special default for liability. Reporting of NOINJ may be submitted if requirements are met.

Self-Insurance Information

Self Insured Indicator*	Self-insurance as defined by CMS if Plan Insurance Workers’ Compensation or Liability.	No Yes
Self-Insured Type	Individual or Other (Business, corporation, organization, company, etc.)
Policyholder Last Name	Surname of policyholder or self-insured individual.
Policyholder First Name	Given/First name of policyholder or self-insured individual.
DBA Name	"Doing Business As" Name of self-insured
Legal Name	Legal Name of self-insured organization/business.
Office Code / Site ID
Plan Insurance Type*	Type of insurance coverage or line of business provided by the plan policy or self-insurance (No-Fault, Workers’ Compensation, or Liability)
TIN*	Federal Tax Identification Number of the “applicable plan” used by the RRE
Policy Number*	The unique identifier for the policy under which the underlying claim was filed.
Claim Number*	The unique claim identifier by which the primary plan identifies the claim.
Plan Contact Department Name	Name of department for the Plan Contact to which claim-related communication and correspondence should be sent.
Plan Contact Last, First Name	Individual who should be contacted at the Plan for claim-related communication and correspondence.
Plan Contact Phone	Include 3 digit area code and extension if available
No-fault Insurance Limit	Dollar amount of limit on no-fault insurance.
No-fault Limit Exhaust Date	Date on which limit was reached or benefits exhausted for No-Fault Insurance Limit

Representative Information (All fields are required if injured party has a representative)

Representative Indicator	Attorney, Guardian/Conservator, Power of Attorney, Other, or None
	Representative’s Federal Tax Identification Number (TIN).
Representative: Last & First Name or Firm Name	Representative Last Name and First Name – or – Representative Firm Name (Either Representative Last Name and First Name - or - Representative Firm Name is required if Injured Party has a representative.)
Address
City, State, Zip
Phone	Include 3 digit area code and extension if available

ORM and TPOC Information

ORM Indicator*	Indication of whether there is ongoing responsibility for medicals (ORM).	No Yes
ORM Termination Date	Date ongoing responsibility for medicals ended, where applicable.
TPOC Date 1	Date of associated Total Payment Obligation to the Claimant (TPOC). Date payment obligation was established.
TPOC Amount 1	Total Payment Obligation to the Claimant (TPOC) amount: Dollar amount of the total payment obligation to the claimant.
Funding Delayed Beyond TPOC Start Date	If funding is delayed, provide actual or estimated date of funding