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Section 111 Mandatory Reporting Application (MRA)
Injured Party Information
Carefully enter required information about the injured party. Ensure that the values entered are correct as a transaction will be deducted from your allotted count whether a beneficiary is found or not.
Enter either the Medicare ID (Health Insurance Claim Number [HICN] or Medicare Beneficiary Identifier [MBI]) or SSN. The Medicare ID is preferred. If both the Medicare ID and SSN are entered, the Medicare ID will be used for the search. Since Medicare IDs can change for a particular beneficiary, the lookup can result in a match, but a different Medicare ID may be returned.
The first initial of the first name, first six characters of the last name, gender, and date of birth comprise the secondary part of the match. Once a match is found for the Medicare ID or SSN, at least 3 out of 4 of these other personal characteristics must also match the beneficiary record for the injured party to be considered found. If you do not have the Medicare ID available, or are unsure of the validity of the Medicare ID, the SSN may be entered. You may choose to enter only the last 5 digits of the SSN instead of the full 9 digits.
Transactions Remaining: RREs are allotted 500 transactions per calendar year. This number represents the number of transactions still available for use. This counter will be automatically reset on the RRE's anniversary of selecting DDE each year. If an RRE is approaching its 500th transaction and is in need of additional transactions, the RRE should contact their EDI Representative.
Claim: This box contains the initial values for the claim record you are entering. The claim add date defaults to today's date. The initial status of the claim and the latest Document control number will be displayed in this box. As you progress through the claim entry process the information you have entered thus far will be displayed here.
Injured Party Information Fields
| Field | Description | Medicare ID |
The Injured Party's Medicare ID (HICN or MBI) assigned by Medicare. Valid Medicare IDs may consist of up to 12 characters. If the Medicare ID is not available an SSN may be entered instead. |
|---|---|
SSN |
The Injured Party's Social Security Number. Valid SSNs consist of 9 numeric digits or the last 5 digits of the SSN. The SSN is only necessary if the Medicare ID is not available. |
First Name |
Enter first name of Injured Party. May contain letters A-Z or a-z and embedded spaces. Enter name as shown on Social Security card or Medicare card. (Required) |
Middle Initial |
Enter first letter of the Injured Party's middle name. Enter 1 alpha character. (Optional) |
Last Name |
Enter the last name the of the Injured Party. May contain letters A-Z or a-z, hyphens, apostrophes, and embedded spaces. Enter name as shown on Social Security card or Medicare card. (Required) |
Gender |
Select sex of Injured Party as Male or Female. (Required) |
Date of Birth |
Birth date of Injured Party. Enter numeric digits 0-9 in MM/DD/CCYY format. (Required) |
Cancel |
Returns to the Claim Listing page. The information you entered will not be saved. |
Next |
Submits information for verification |
Use the Home link on the menu to return to the RRE Listing page.