Section 111 Mandatory Secondary Payor Reporting. Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (“MMSEA”), titled Medicare Secondary Payor, (hereinafter “Section 111”) mandates that, effective January 1, 2009, all group health plans or their representatives submit certain information to Center of Medicare & Medicaid Services. BlueCross is registered as a medical “Required Reporting Entity” as required under Section 111. BlueCross shall report the Plan’s medical information required by Section 111. Under no circumstances will BlueCross be required to report workers’ compensation or liability insurance information required under Section 111. Employer shall provide all Social Security numbers, tax identification numbers, and the “total number of employees” (as that is defined in the MMSEA) information to BlueCross. BlueCross will not be responsible for any deficiency resulting from Employer’s failure to provide such information to BlueCross. BlueCross BlueShield of Tennessee, Inc. Town of Ashland City By: By: Printed Name: Printed Name: Title: Title: Date: Date: Address: Address: 000 Xxxxxxxxx Xxxxx Xxxxxxx Ashland, TN 37015 Employer ID No. 00-0000000 DIRECT DEBIT AUTHORIZATION AGREEMENT The Employer has signed a separate Direct Debit Authorization Agreement, which is hereby incorporated by reference as part of this Agreement. BUSINESS ASSOCIATE AGREEMENT Between BLUE CROSS BLUE SHIELD OF TENNESSEE, INC. and Town of Ashland City This Business Associate Agreement (“BAA”) is effective upon execution and amends and is made part of the Administrative Services Agreement (“ASA”) by and between BlueCross BlueShield of Tennessee, Inc. (“BlueCross”), Town of Ashland City (“Employer”) assigned Employer Group Number 125011, and the Group Health Plan (“GHP”). The ASA is modified to incorporate the terms of this HIPAA Agreement to comply with the requirements of the implementing regulations at 45 Code of Federal Regulations (“C.F.R.”) Parts 160- 64 for the Administrative Simplification provisions of Title II, Subtitle F of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), as modified by the Health Information Technology for Economic and Clinical Health Act, as incorporated in the American Recovery and Reinvestment Act of 2009 (“HITECH Act”), and the implementing regulations (“HIPAA Rules”) that are applicable to BlueCross, along with any guidance and/or regulations issued by United States Department of Health and Human Services (“DHHS”). BlueCross and GHP agree to incorpo...
Section 111 Mandatory Secondary Payor Reporting. Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA), titled Medicare Secondary Payor, (hereinafter “Section 111”) mandates that, effective January 1, 2009, all group health plans or their representatives submit certain information to CMS. BlueCross is registered as a medical “Required Reporting Entity” as required under Section 111. BlueCross shall report the Plan’s medical information required by Section 111. Under no circumstances will BlueCross be required to report workers’ compensation or liability insurance information required under Section 111. Employer shall provide all Social Security numbers, tax identification numbers, and the “total number of employees” (as that is defined in the MMSEA) information to BlueCross. BlueCross will not be responsible for any deficiency resulting from Employer’s failure to provide such information to BlueCross.
