CMS Releases New WCMSA Reference Guide and NGHP Section 111 User Guide

By Shawn Deane, Sidney Wong  |  October 5, 2018

The Centers for Medicare and Medicaid Services (CMS) has updated its Workers' Compensation Medicare Set-Aside (WCMSA) Reference Guide and Non-Group Health Plan (NGHP) Section 111 User Guide.

These new updates include the following:

New WCMSA Reference Guide (Version 2.8, October 1, 2018)

The main change relates to CMS’ ongoing Social Security Number Removal Initiative (SSNRI) and Medicare Beneficiary Identifier (MBI) process through which CMS is required to reissue new Medicare cards removing the current SSN-based number with a new unique MBI. CMS is currently reissuing the cards in geographic waves and is required to have all new Medicare cards issued by April 2019.

In relation to this, the new WCMSA Reference Guide was updated to align with the MBI changes. In a going forward basis, CMS will be using a MBI, instead of a Health Insurance Claim Number (HICN), when identifying beneficiaries in WCMSAs. However, parties can still submit the HICN to CMS. Outside of this, CMS updated the charts for determining jurisdiction when calculating the pricing in the WCMSA. The methodology to determine the applicable jurisdiction did not change, but CMS provided some additional clarity and context through examples. CMS also introduced a new chart that matched the resulting jurisdiction with the applicable pricing schedule. Finally, CMS updated the link to the current Centers for Disease Control (CDC) life expectancy table.

New NGHP User Guide (Version 5.4, October 1, 2018)

There were changes made to the Sec. 111 NGHP User Guide in this most recent version. These updates include, per their respective chapter, the following:  

Chapter 1

  • To meet Section 111 requirements, a Paperwork Reduction Act (PRA) disclosure statement has been added to this guide.
  • The contact protocol for the Section 111 data exchange escalation process has been updated (Section 8.2).

Chapter 2

  • The contact protocol for the Section 111 data exchange escalation process has been updated (Section 7.2).

Chapter 3 – No updates

Chapter 4

  • To ensure updates are applied to recovery cases appropriately, RREs are asked to submit the policy number uniformly with a consistent format. When sending updates, enter the policy number exactly as it was entered on the original submission, whether blank, zeros, or a full policy number (Section 6.6.5).
  • The contact protocol for the Section 111 data exchange escalation process has been updated (Section 13.2).

Chapter 5

  • To ensure updates are applied to recovery cases appropriately, RREs are asked to submit the policy number uniformly with a consistent format. When sending updates, enter the policy number exactly as it was entered on the original submission, whether blank, zeros, or a full policy number (Appendix A, Claim Input File, Field 54).
  • Placement of decimals for the ICD-10 Excluded “Y” diagnosis codes has been corrected (Appendix I).
  • The excluded and no-fault excluded ICD-10 diagnosis codes have been updated for 2019(Appendix I and Appendix J).

If you have any questions regarding these updates, please contact the authors directly.


Shawn Deane

Shawn Deane is vice president of Medicare / Medicaid compliance and policy at ISO Claims Partners where he concentrates on all facets of Medicare Secondary Payer (MSP) compliance. Before joining ISO Claims Partners, he practiced healthcare law and insurance defense. Shawn is a member of the Defense Research Institute, has attained the Medicare Set-Aside Certified Consultant (MSCC) certification, and is the 2017 President of the National Alliance of Medicare Set-Aside Professionals (NAMSAP). He is member of the Massachusetts Bar and is licensed in both state and federal courts in Massachusetts.

Sidney Wong

Sidney Wong is the assistant vice president of policy at ISO Claims Partners, where he provides the highest level of client services—with a focus on meeting the needs of clients through ISO’s products and services. He is also responsible for assisting clients with effectively navigating Medicare compliance issues.