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    Pennsylvania Insurance Department

    MCARE Claims

    Claims Reporting

    When patients sue a physician, hospital, or other health care provider covered by the Mcare Act, the Mcare Fund is typically involved in the claims handling process and often in any payment made to the patient.  The Mcare Fund routinely plays the role of informal mediator bringing a global perspective to cases with multiple defendants.  The Mcare Fund also provides an efficient, neutral, and broadly accepted alternative dispute platform that allows for the more efficient resolution of claims that should be settled but need a process to help this occur.

    Excess Claims Reporting

    If all statutory requirements are satisfied, Mcare provides coverage in excess of the applicable primary coverage. If it is anticipated that a judgment, award, or settlement in a particular case will exceed the available primary coverage for a health care provider, the primary insurer must promptly notify Mcare in writing of the medical professional liability claim. This notification must be made through submission of a Form C-416 to Mcare.

    Section 715 Claims Reporting

    Section 715 of Act 13 provides an exception to Mcare’s statutory role of providing excess coverage in instances where the claim criticizes treatment prior to January 1, 2006. Under Section 715, Mcare provides first dollar indemnity up to $1,000,000 and the cost of defense for a claim if certain requirements are met. Specifically, the claim must be filed more than four years after the date the breach of contract or tort occurred, must be filed within the applicable statute of limitations, and the primary insurer must submit a Form C-416 requesting Section 715 status for the claim within 180 days of the date on which notice of the claim was first given to the health care provider or its insurer. In the event of multiple treatments occurring less than four years before the date on which the health care provider or its insurer received notice of the claim, Section 715 coverage will not apply.

    Pursuant to Act 13, Section 715 coverage ends as of January 1, 2006. Specifically, primary insurers are required to provide first dollar indemnity and cost of defense for all claims occurring four or more years after the breach of contract or tort and after December 31, 2005.

    Form C-416 Claim Reporting

    New C-416 Claim Reporting Guidelines have been developed to assist primary insurers through the email submission process, as well as the fax and US Mail process.

    Submit the completed C-416 to: ra-in-mc-c416claim@pa.gov

    Request for Claims History 

    Mcare will provide a Health Care Provider or an authorized person/entity with a Claims History (also referred to as “Loss Run”) upon request.

    To be completed, all requests must contain the necessary elements of a connection to a Health Care Provider and proper authorization.

    Facility Requests -  Letterhead and position title with signature serves as authorization for facilities requesting their own information. Include the name, email and/or address where the information is to be sent. Indicate the Claims History date range or “all history” for a full report.

    Individual Health Care Provider Requests – include the following information:

    • Name of Health Care Provider
    • PA License Number
    • Claims History date range or "all history" for a full report
    • Signature of the Health Care Provider
    • Signature of person and/or Name of entity authorized to receive the Claims History
    • Name, email and/or address where the information is to be sent, as in the case of a Health Care Provider directing it to a facility or credentialing agency 

    Email the required documentation to  RA-IN-CLAIMCOVERAGEINFO@pa.gov. 

    Requests will be accepted by Fax (717) 787-0651 and US mail.

    Call us at (717) 783-3770 or email RA-IN-CLAIMCOVERAGEINFO@pa.gov with any questions.

    Aggregate Erosion Reporting

    It is important that the primary insurers notify Mcare when payments have been made under the primary insurance coverage reach a point where additional monitoring of the aggregate limits should take place. Mcare has updated this reporting process.

    FORM AEF-1 EROSION OF PRIMARY AGGREGATE LIMITS REPORTING

    New Aggregate Erosion Guidelines have been developed to assist primary insurers through the process of completing and submitting Form AEF-1.

    Submit the completed AEF-1 to: ra-in-aggerosion@pa.gov

    Medicare Secondary Payer Reporting (MSP)

    Under federal law, Medicare may be entitled to repayment of payments it makes for certain medical treatments, if the need for the medical treatment is later determined to be caused by another person and/or entity. Medicare is the "secondary payer" since the person and/or entity causing the need for the medical bills should be first in line to make the payments with Medicare being second in line. The federal law requires primary insurers and Mcare to report specific claim related details and information on the payments they make on medical malpractice claims to Medicare. For an overview of the Mandatory Insurer Reporting process, including registration and reporting requirements, please click Mandatory Insurer Reporting for Non-Group Health Plan (NGHP).

    FORM FOR MSP PRIMARY CARRIER REPORTING

    To assist Mcare in its reporting obligations, primary insurers are asked to notify Mcare at the same time they report a medical malpractice payment to CMS based on the federal law using the form below.

    Questions should be directed to Mcare at (717) 783-3770

    Submit the completed MSP Primary Carrier Reporting Form to:  ra-in-mcare-msp@pa.gov

    Qualified Annuity Companies

    Section 509 of the Mcare Act provides for the funding of an award of periodic payments by an annuity contract issued by annuity companies receiving the highest rating for claims paying ability by two independent financial services within the last 12 months. Click here to view the current list.

    Claims Contact Information

    Telephone: (717) 783-3770
    Fax: (717) 787-0651