NGHP S 111 policy alert regarding no-fault policy limits

By Mark Popolizio, J.D., Jeremy Farquhar

October 28, 2021 / 2 min read

The Centers for Medicare and Medicaid Services (CMS) has released a new Non-Group Health Plan (NGHP) Section 111 Policy Alert addressing the reporting of incorrect no-fault policy limits. In this new Alert, CMS discusses various situations involving no-fault policy limits reporting and how incorrect reporting could place Responsible Reporting Entities (RREs) at risk for non-compliance with the Section 111 reporting requirements and impact Medicare recovery actions.

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Overall, the Alert does not contain any new policy or technical changes. Rather, CMS essentially reiterates long-standing reporting guidelines, while also highlighting the potential negative consequences of incorrect no-fault policy limit reporting.

Below is the information contained in CMS’s Alert broken down using bullet formatting for a more convenient presentation of the informational points:

Responsible Reporting Entities (RREs) are accountable for ensuring the information included in their Section 111 MMSEA Mandatory Insurer Reporting submissions is accurate.

There may be situations where, depending upon state law or the terms of a given policy, the policy limit may vary. In these situations, the reported Policy Limit should reflect the actual amount the RRE has accepted responsibility for at the time the record is submitted or updated.

Just as important, if the Section 111 record needs to be corrected to reflect a different Policy Limit, the RRE should update the record as quickly as possible to reflect the new policy limit. For example, if a policy allows for a minimum amount of Med Pay coverage and will only allow a higher amount under certain circumstances, and those circumstances are not yet met at the time of reporting, the RRE should report the lower amount. Should the criteria that trigger the higher policy limit be met after that report, the RRE should update the record as soon as possible.

Reporting of an incorrect Policy Limit or failing to timely update the record can put the RRE at risk of non-compliance with the Section 111 reporting

Inaccurate and/or uncorrected information can impact current Medicare claims payment actions.

Inaccurate and/or uncorrected information also places the RRE at risk of recovery actions and increases the burden of proof upon the RRE should it attempt to dispute recovery efforts. Therefore, we advise the RRE to consider contacting their EDI Representative to submit an off-cycle Section 111 report with new policy limit information, rather than wait for their next Section 111 reporting cycle.

Questions?

Please do not hesitate to contact the authors if you have any questions regarding CMS’s new Alert or any other issues related to Section 111 reporting.

CMS releases new NGHP Section 111 policy alert regarding the reporting of incorrect no-fault policy limits

Questions?