Case Information Screen Liability
Plaintiff Information
Fields marked with a
red asterisk mark (*)
are mandatory.
*
Last Name
Last Name is required
Last Name contains Invalid characters
*
First Name
First Name is required
First Name contains Invalid characters
*
SSN
(xxx-xx-xxxx)
Please fill out the Social Security Number.
Please fill in the correct Social Security Number.
*
Date of Birth (
mm/dd/yyyy
)
Please fill in a Date of Birth.
Please fill in a valid Date of Birth.
Date of Birth must be less than today's date.
*
Gender
Male
Female
Gender is required
Street Address
Street Address contains Invalid characters
City:
City contains Invalid characters
State
select
Please Select
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Zip contains Invalid characters
*
Claim Number
Claim Number is required
Claim Number contains Invalid characters
*
Date of Accident
(mm/dd/yyyy)
Please fill in a Date of Accident.
Please fill in a valid Date of Accident.
Date of Accident must be less than today's date.
*
State of Jurisdiction
select
Please Select
AK
AL
AR
AZ
CA
CO
CT
DC
DE
Defense Base Act
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
Long Shore
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
US
UT
VA
VI
VT
WA
WI
WV
WY
Please include State of Jurisdiction.
*
Case Type
General Liability Policy
Med-Pay (No-Fault)
Premises Liability
Auto Policy
Med-Pay (No-Fault)
Personal Injury Protection (PIP) (No-Fault)
Liability
Medical Malpractice
Other
Select valid Case Type
*
Self-Insured
Yes
No
Self Insured is required
*
Carrier
Please include the Carrier information.
Carrier contains Invalid characters
*
TPA/Servicing Agent
Please include the TPA/Servicing Agent information.
TPA/Servicing Agent contains Invalid characters
Excess Carrier
Excess Carrier contains Invalid characters
Defendant/Insured Name
Defendant/Insured Name contains Invalid characters
Responsible Reporting Entity (RRE)
Responsible Reporting Entity (RRE) contains Invalid characters
Contact Information
Who is the referring source?
select
Adjuster
Defense Attorney
Plaintiff/Claimant Attorney
Structured Settlement Broker
Please complete all known contact information for the following:
*
Adjuster Name
Please include Adjuster Name.
Adjuster Name contains Invalid characters
*
Phone Number
Please include Adjuster Phone Number.
Adjuster Phone Number needs to be in the following format xxx.xxx.xxxx.
Fax Number
Adjuster Fax Number needs to be in the following format xxx.xxx.xxxx.
*
Company
Please include Adjuster Company.
Company contains Invalid characters
Email Address
Adjuster E-Mail Address is invalid. Please type in a valid E-Mail Address
Adjuster Mailing Address
Address
Adjuster Mailing Address contains Invalid characters
City
Adjuster Mailing City contains Invalid characters
State
select
Please Select
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Adjuster Mailing Zip contains Invalid characters
Adjuster Physical Address
Address
Adjuster Physical Address contains Invalid characters
City
Adjuster Physical City contains Invalid characters
*
State
select
Please Select
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Please include Adjuster State.
Zip
Adjuster Physical Zip contains Invalid characters
Defense Attorney
Name
Attorney Name contains Invalid characters
Phone Number
Attorney Phone Number needs to be in the following format xxx.xxx.xxxx
Fax Number
Attorney Fax Number needs to be in the following format xxx.xxx.xxxx.
Defense Firm
Defense Firm contains Invalid characters
Email Address
Attorney E-Mail Address is invalid. Please type in a valid E-Mail Address
Address
Attorney Address contains Invalid characters
City
Attorney City contains Invalid characters
State
select
Please Select
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Attorney Zip contains Invalid characters
Plaintiff/Claimant Attorney
Name
Plaintiff Name contains Invalid characters
Phone Number
Plaintiff Phone Number needs to be in the following format xxx.xxx.xxxx
Fax Number
Plaintiff Fax Number needs to be in the following format xxx.xxx.xxxx
Plaintiff/Claimant Firm
Plaintiff Firm contains Invalid characters
Email Address
Plaintiff E-Mail Address is invalid. Please type in a valid E-Mail Address
Address
Plaintiff Address contains Invalid characters
City
Plaintiff City contains Invalid characters
State
select
Please Select
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Plaintiff Zip contains Invalid characters
Structured Settlement Broker
Name
Broker Name contains Invalid characters
Phone Number
Broker Phone Number needs to be in the following format xxx.xxx.xxxx
Fax Number
Broker Fax Number needs to be in the following format xxx.xxx.xxxx.
Firm
Broker Firm contains Invalid characters
Email Address
Broker E-Mail Address is invalid. Please type in a valid E-Mail Address
Address
Broker Address contains Invalid characters
City
Broker City contains Invalid characters
State
select
Please Select
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Broker Zip contains Invalid characters
*
Service Requested:
Please call 888.672.7674 with any questions.
To prevent delays or complications with completing the requested service please confirm the information reported to Medicare through Section 111 reflects what is being provided on the referral form for the requested service.
Atleast one checkbox from Service Requested should be checked
MSA Compliance Solutions
Social Security Verification
Liability MSA requested upon verification of SS benefits?
Yes
No
OR
Liability Future Medical Allocation(LFMA) requested upon verification of SS Benefits?
Yes
No
Liability Medicare Set-Aside Allocation(LMSA)** Settlement amount anticipated to be enough to fully fund a LMSA or noncovered medical expenses
Rush service available for an additional charge.
Rush needed?
N/A
5-Day
2-Day
Annuity Quote(if applicable)(rush not available)
Yes
No
Equitably Apportioned LMSA Option (is an add on service that is needed when settlement amount is not enough to fully fund LMSA, pay claimant’s attorneys fees/costs/expenses, reimburse provider liens, reimburse Medicare conditional payments and provide claimant a reasonable lump sum)
Full Case Value per claimant’s attorney *:
$
Total Settlement Amount (gross):
$
Amount of claimant attorney’s fees/costs:
$
Provider liens to be reimbursed:
$
Medicare Conditional Payment Amount to be reimbursed:
$
*Claimant attorney’s value of the case on his/her best day in front of a jury where his witnesses, expert opinions and evidence is viewed in a favorable light. Claimant’s attorney’s assessment of what the case is worth.
Revision
Rush needed?
N/A
5-Day
2-Day
Rated Age Only
CMS Submission
CMS Amended Review
Conditional Payment Compliance Solutions
Conditional Payment Verification
Conditional Payment Analysis
Conditional Payment Dispute
Conditional Payment Appeal
Final Demand
Treasury Resolution
Medicare Advantage Plan Verification
Medicare Advantage Plan Analysis/Dispute
Medicaid Lien Verification
Verification
Analysis
Dispute filling
Claim Forecasting Solutions
Liability Future Medical Allocation(LFMA)**
Rush service available for an additional charge.
Rush needed?
N/A
5-Day
2-Day
Annuity Quote(if applicable)(rush not available)
Yes
No
Limited Liability Future Medical Allocation
Rush service available for an additional charge.
Rush needed?
N/A
5-Day
2-Day
Clinical Cost Containment Solutions
Medication Analysis
Peer to peer outreach?
Yes
No
Nurse progress monitoring?
Yes
No
MSA Funds Administration
Assisted Administration
Additional Information
Notes:
(Please include any information related to this file not otherwise noted. Maximum 5000 characters are allowed.)
Notes contains Invalid characters
Pertinent Information Related to the File:
*
What diagnoses/body part(s) are claimed/treated in this claim?
Please include the accepted diagnoses/body part(s) information.
Claimed/treated Diagnoses/body part(s) contains Invalid characters
What diagnoses/body part(s) are pre-existing or exacerbated in this claim?
Pre-Existing diagnoses/body part(s) contains Invalid characters
What is the proposed settlement amount?
Proposed Settlement Amount contains Invalid characters
Please note, CMS shares Section 111 reporting data with the Workers’ Compensation Review Center (WCRC), Benefits Coordination Recovery Center (BCRC), Commercial Repayment Center (CRC) and Medicare Advantage Plans (MAP) to aid in the recovery of conditional payments and the approval of the Medicare Set-Aside. Optum encourages a review of the ICD codes, Ongoing Responsibility of Medical (ORM) and Total Payment Obligation to Claimant (TPOC) information provided through Section 111 mandatory insurer reporting, to ensure accurate reporting, as Medicare’s claims processing contractors will use this information to pay or deny medical bills accordingly.
“The CMS portal used to submit MSAs to the WCRC for approval does not accept a file that has both ICD-9 and ICD-10 codes. If this MSA is to be submitted to CMS for approval the codes will need to up updated to whatever codes have been provided through MMSEA Section 111 reporting (ICD-9 if pre 10/5/15 DOA or ICD-10 if post 10/5/15 DOA). To aid in the conversion Optum provides an ICD look up tool which can be accessed by clicking https://medicareconnect.optum.com/.”
Unless otherwise indicated, the referring party will be responsible for all payments.
**Cancellation of referral after work has commenced is subject to a fee of 25% of the original cost for the service.
If you would like an email confirmation, please enter your email address below. If you would like to send to multiple email addresses, please enter each address separated by a semi-colon. If you have already provided an email address in the Adjuster Contact Information section of this form, you will automatically receive an email confirmation.
Confirmation Email
Confirmation E-Mail is invalid. Please type in a valid E-Mail address.
Please indicate the Optum Settlement Solutions Associate that worked with you on this file:
Settlement Solutions Associate contains Invalid characters
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