CMS Releases New Section 111 NGHP User Guide (Version 5.3)

By Mark Popolizio  |  December 21, 2017

The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 non-group health plan (NGHP) User Guide (Version 5.3, December 15, 2017). This new User Guide replaces Version 5.2 which CMS released in January 2017.

The new updates relate to the following areas:

Medicare Identifier

The bulk of the updates encapsulate CMS’ prior policy statements related to the agency’s on-going social security number removal initiative (SSNRI) as required under Section 501 of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. This law requires CMS to discontinue all SSN-based Medicare identifiers and requires the agency to replace all Medicare cards with a new unique 11-byte Medicare Beneficiary Identifier (MBI) by April 2019. CMS will begin reissuing new Medicare cards in April 2018 and has one year to complete this task. The main objective behind this new law is to reduce identity theft.

It is important to note that MACRA contains a specific Medicare Secondary Payer (MSP) exemption, which will provide claims payers with flexibility in dealing with CMS on MSP matters. For example, CMS indicates that NGHP Responsible Reporting Entities (RREs) are still allowed to report the full SSN, the health insurance claim number (HICN), or the new MBI for Section 111 reporting purposes.

To accommodate the MACRA changes, CMS’ new User Guide updates reflect that all fields formerly labeled as “HICN” have been relabeled as “Medicare ID” and can accept either a HICN or the new MBI. Further, CMS indicates that it will return the most current Medicare ID (HICN or MBI) as part of the Section 111 response file in the “Medicare ID” field. In relation to this, CMS states “[c]onsequently, if an RRE submits information with a HICN and the Medicare beneficiary has received their MBI, the MBI will be returned. Otherwise, the most current HICN will be returned.” CMS will permit RREs to submit subsequent Section 111 information using either the HICN or MBI.

With respect to Direct Data Entry (DDE) users, CMS indicates that they will be able to search for saved and submitted claims using the HICN or MBI. DDE users should consult the User Guide for further details in terms of how this will work.

CMS further indicates that RREs will still be able to use the SSN to query via the HEW 270/271 query process with the most current Medicare identifier (either the HICN or MBI) returned in the “Medicare ID” field.

On another front, the new updates also reflect that correspondence from the Benefits Coordination and Recovery Center (BCRC) and Commercial Repayment Center (CRC) will use the Medicare Identifier that the RRE most recently provided when creating an MSP record.

Other Updates

CMS’ new User Guide also makes updates regarding the Retiree Drug Subsidy (RDS); RDS unsolicited response file; contact protocol for Section 111 data escalation process, and updated ICD-10 exclusions (Appendix I and J). CMS also added a new ORM termination section (6.3.2) indicating that when ORM ends the RRE should report the date ORM terminated but should not delete the record, along with reiterating and clarifying when ORM termination is/is not appropriate with respect to claims where ORM is subject to reopening or otherwise subject to an additional request for payment.

Going Forward

ISO CP will continue to monitor all developments on these fronts and provide updates as warranted. For our MSP Navigator and ClaimSearch CMS customers, we will be in touch in the new year to discuss any testing needs as warranted in relation to operationalizing the Medicare identifier changes.

To review CMS’ new User Guide, click here. To learn more about CMS’ SSNRI/MBI initiative, see the author’s recent webinar on this topic here.

Please contact the author directly with any questions at mpopolizio@iso.com or 786.459.9117.


Mark Popolizio

Mark Popolizio is the Vice President of MSP Compliance and Policy for ISO Claims Partners. Mark’s area of specialty is Medicare secondary payer compliance. He authors regular articles and provides educational presentations across the country on MSP issues. Mark's e-mail address is mpopolizio@iso.com.