Attachment C Quarterly Report Format.xls

This is a Quarterly Report Format template document prepared by the State of Wisconsin Department of Administration, Bureau of State Risk Management in connection with Workers' Compensation Center for Medicare Reporting Compliance Services. The template establishes the standardized format and data fields required for quarterly submission of workers' compensation claims information to the Centers for Medicare and Medicaid Services (CMS) under the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA). The report format captures essential claim and transaction data including claim numbers, claimant names, disposition codes, insurer names, employer names, third-party administrator (TPA) names, submission dates, and response dates. This reporting requirement ensures the State of Wisconsin's compliance with federal mandates effective April 1, 2010, which obligate the state to submit reports on workers' compensation payments to the U.S. Department of Health and Human Services.

The template specifies data fields for cms_response_manager tracking, resubmit and delete transactions, subsequent referrals, error codes, and compliance codes to monitor the quality and accuracy of claims reporting submissions. The structured format includes provision for claim record identification and history record types to maintain a comprehensive audit trail of all submissions. This quarterly reporting mechanism serves as the operational vehicle through which the State fulfills its federal compliance obligations under MMSEA for workers' compensation, self-insurance, no-fault insurance, and liability insurance reporting across all state workers' compensation programs.