ORM & TPOC Claim Information Form

* indicates a required field
Injured Party Information
Last Name*
First Name*
Middle Initial
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.)
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