CMS releases NGHP User Guide (Version 7.3)

By Mark Popolizio, J.D., Jeremy Farquhar

August 8, 2023 / 9 min read

The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 NGHP User Guide (Version 7.3, August 7, 2023) regarding Section 111 reporting related to non-group health plans (liability, no-fault and workers’ compensation).

As usual, CMS lists the new updates in the beginning of each User Guide chapter in a “Summary” page. Reviewing these pages indicates that updates were made to Chapter 1 (Introduction and Overview), Chapter II (Registration Procedures), Chapter III (Policy Guidance) and Chapter IV (Technical Information) as more fully outlined below.

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The following provides an overview of the changes made in NGHP User Guide (Version 7.3):

CMS makes further updates to its ORM reporting trigger guidelines

As part of the Summary Update page to Chapter III, CMS states as follows: “The section on Ongoing Responsibility for Medicals (ORM) reporting has been updated to clarify what triggers ORM and how that relates to any payments that have been made for the treatment in question (Section 6.3).”^[1] These updates, as discussed below, come on the heels of other recent changes CMS made to Chapter III, Section 6.3 just about two months ago as part of its User Guide (Version 7.2) updates.

More specifically, CMS, as part of its new User Guide (Version 7.3) updates, has now revised its ORM reporting trigger guidelines to read in full as follows:

The trigger for reporting ORM is the determination to assume ORM by the RRE, which is when the RRE learns, through normal due diligence, that the beneficiary has received (or is receiving) medical treatment related to the injury or illness sustained. Required reporting of ORM by the RRE does not necessarily require the RRE to have made payment for Medicare-covered items or services when the RRE assumed ORM, nor does a provider or supplier necessarily have to have submitted a claim for such items or services to the RRE for the RRE to assume ORM. The effective date for ORM is the DOI, regardless of when the beneficiary receives the first medical treatment or when ORM is reported.^[2]

Thus, the above language now sets-forth CMS’s guidelines regarding the ORM reporting trigger and replaces the previous language contained in Section 6.3.

Keeping in the mind the above updates to Section 6.3, let’s unpack CMS’s changes in a bit more detail to help place them in better context in the larger picture of Section 111 reporting as follows:

How has CMS revised the Section 6.3 language from the previous User Guide (Version 7.2) updates? What are some remaining questions?

In the big picture, the revised language contained in Section 6.3 noted above appears to be an attempt by CMS to clarify the ORM trigger language released as part of its short-lived updates made to Section 6.3 contained in User Guide (Version 7.2, June 5, 2023).

By way of brief background, as part of CMS’s prior User Guide (Version 7.2) updates, CMS revised Section 6.3 to read, in relevant part, that “[t]he trigger for reporting ORM is the assumption of ORM by the RRE, which is when the RRE has made a determination to assume responsibility for ORM and when the beneficiary receives medical treatment related to the injury or illness.” (authors’ emphasis).^[3]

As reported by the authors in our recent article, CMS’s addition of the italicized language to its ORM reporting trigger guidelines was a significant development in that up until that point (from the start of Section 111 reporting) per CMS’s guidelines ORM was assumed when the RRE simply “made a determination to assume ORM” -- without any consideration regarding whether the claimant ever actually received medical treatment. Thus, the above italicized language added a second element to the ORM definition – namely, that in addition to making a “determination” to assume ORM, the beneficiary would have also had to “receive” medical treatment for the ORM reporting trigger to be met.^[4]

Overall, the changes made by CMS to Section 6.3 in prior User Guide (Version 7.2) refined the scenarios in which CMS would require RREs to report ORM and, in part, eliminated the need to report ORM in scenarios where no medical treatment had been received in connection to the incident in question. This, as noted in the authors’ recent article, was likely viewed by many RREs as a positive and helpful step. However, this additional language raised certain questions. Namely, what CMS’s expectations might be in terms of steps RRE may be expected to take to determine if treatment had been received if the injured party failed to subsequently notify the RRE that he or she had received medical treatment of which the RRE was unaware.

Against this backdrop, and in an apparent attempt to further clarify this point, CMS as part of the new User Guide (Version 7.3 updates) has now revised the language of the second ORM trigger. Specifically, CMS has replaced the phrase “and when the beneficiary receives medical treatment related to the injury or illness” with the phrase “which is when the RRE learns, through normal due diligence, that the beneficiary has received (or is receiving) medical treatment related to the injury or illness sustained.”

Thus, when the dust settles here, this part of CMS’s ORM reporting trigger, as noted above, revises Section 6.3, in pertinent part, to now read as follows: “The trigger for reporting ORM is the determination to assume ORM by the RRE, which is when the RRE learns, through normal due diligence, that the beneficiary has received (or is receiving) medical treatment related to the injury or illness sustained.” (author’s emphasis).^[5] Of note, CMS has not provided any further guidance as to what may be considered “through normal due diligence” in relation to this verbiage. As such, going forward, this will appear to be a judgment call for RREs to make.

Taking a look at the remaining parts of the revised Section 6.3 verbiage, it will be noted that CMS has retained the language that actual payments to do not have to be made for an RRE to have ORM – which has been part of CMS’s ORM reporting trigger from the start of the Section 111 reporting process. Specifically, as noted above, the updated Section 6.3 language contains, similar to prior versions of this section, the following verbiage: “[r]equired reporting of ORM by the RRE does not necessarily require the RRE to have made payment for Medicare-covered items or services when the RRE assumed ORM, nor does a provider or supplier necessarily have to have submitted a claim for such items or services to the RRE for the RRE to assume ORM.” (author’s emphasis).^[6]

On this point, as noted in the authors’ recent article, this language (and the concept that ORM can still be assumed without payment by the RRE, or without a provider submitting a claim to the RRE) will likely continue to also raise questions for RREs in terms of what CMS may expect from RREs to determine whether the claimant has actually received medical treatment. As noted above, the new verbiage indicates ORM is assumed, in part, “when the RRE learns, through normal due diligence, that the beneficiary has received (or is receiving) medical treatment related to the injury or illness sustained.” However, as noted, CMS has not provided any further guidance as to what may constitute “through normal due diligence.”

Thus, on this point, the question that appears to remain is, if the assumption of ORM does not require the RRE to have received a claim for items or services, or that the RRE has made payment in relation to any claim for items or services, what are CMS’s expectations relating to additional efforts expected of an RRE to appropriately determine whether treatment has been received? From the authors’ perspective, this question appears to remain nearly as unclear as it had been under CMS’s previous Section 6.3 verbiage.

NGHP Section 111 Unsolicited Response File Updates

As part of the changes noted in the Summary Update page to Chapter IV, CMS states: “The guide has been updated to inform users who have opted [into] the unsolicited response file process that they may receive an empty file if no updates were made to their records in the reporting period, and that the file is received in the claim response file folder (Section 7.5).” In addition, CMS also added the following language to Section 7.5: “If there are no changes to existing records for the most recent reporting period, the file will still be sent but will be empty (header and trailer records only). It will appear in the claim response file folder.”

Overall, this update would appear to make sense as receipt of an empty file will serve to confirm for the RRE that no changes had been applied to any of their Section 111 ORM records throughout the calendar month in question. On the contrary, if CMS were to refrain from returning a file altogether in such scenarios, RREs might not be certain whether there could have been a problem which prevented the successful upload of their file or if they might have missed something somehow. That said, the empty files did elicit a significant number of questions from RREs at the time CMS posted the first round of files in July and this additional language should help to eliminate any potential confusion.

To learn more about CMS’s NGHP Unsolicited Response File “opt-in” feature, see our following resources:

References to “Internet Explorer” are removed

In addition to the above, CMS, as part of the Summary Update pages to Chapters I, II, and IV, indicate that “[a]ll mentions of Internet Explorer have been removed as it is no longer a supported browser.”

Questions?

Of course, please do not hesitate to contact the authors if you have any questions regarding the above, or Section 111 reporting questions in general.

[1] CMS’s Section 111 NGHP User Guide (Version 7.3, August 7, 2023), Chapter III, Summary of Version 7.3 Updates, p. 1-1.

[2] CMS’s Section 111 NGHP User Guide (Version 7.3, August 7, 2023), Chapter III, Section 6.3.

[3] CMS’s Section 111 NGHP User Guide (Version 7.2, June 5, 2023), Chapter III, Section 6.3.

[4] See, CMS’s Section 111 NGHP User Guide (Version 7.2, June 5, 2023), Chapter III, Section 6.3. Of note, as contained in CMS’s Section NGHP User Guide (Version 7.2, June 5, 2023), Section 6.3 read, in pertinent part, as follows: “The trigger for reporting ORM is the assumption of ORM by the RRE, which is when the RRE has made a determination to assume responsibility for ORM and when the beneficiary receives medical treatment related to the injury or illness. Medical payments do not actually have to be paid, nor does a claim need to be submitted, for ORM reporting to be required. The effective date for ORM is the DOI, regardless of when the beneficiary receives the first medical treatment or when ORM is reported.” Id

[5] CMS’s Section 111 NGHP User Guide (Version 7.3, August 7, 2023), Chapter III, Section 6.3.

[6] CMS’s Section 111 NGHP User Guide (Version 7.3, August 7, 2023), Chapter III, Section 6.3.