CMS releases Section 111 NGHP User Guide (Version 8.0)

By Jeremy Farquhar, Mark Popolizio, J.D.

April 11, 2025 / 9 min read

The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 NGHP User Guide (Version 8.0, April 7, 2025) regarding Section 111 reporting related to non-group health plans (NGHPs) (liability, no-fault and workers’ compensation).

man on mobile phone looking at laptop

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 II (Registration Process); Chapter III (Policy Guidance), Chapter IV (Technical Information); and Chapter V (Appendices).

As discussed more fully below, CMS’s changes include TPOC/WCMSA updates, Event Table updates, a “clarification” regarding the TPOC reporting threshold for no-fault and workers’ compensation cases, and various updates to the User Guide’s appendices.

The authors provide the below overview of CMS’s updates as follows:

TPOC/WCMSA updates

As part of its updates to Chapters II, III, IV, and V, CMS notes that “[t]o align with new WCMSA reporting requirements effective April 4, 2025, field numbers have been updated throughout this guide.”^[1]With the newly introduced fields pertaining to TPOC/WCMSA reporting, field numbers within the Claim Input File have been updated.^[2]The new fields have been added within space previously allotted to field 37 (prior positions 302 – 408) which had been labeled as “Reserved for Future Use.” The new WCMSA related data elements are now located within current fields 37 to 43. While additional filler spaces remain from the prior field 37, those remaining filler spaces are now found in current field 44 (positions 362 – 408) which is now similarly labeled as “Reserved for Future Use.” All subsequent field numbers within the Claim Input File layout (prior fields 37 and onward which are now current fields 44 and onward) have been updated accordingly. Furthermore, all specific field references within Chapters III, IV and V have been similarly updated in accordance with the Claim Input File layout changes.

Event Table Updates (Addressing scenarios when MSA corrections are necessary)

In addition, as part of the Chapter IV updates, CMS also notes that “[t]he Event Table has been updated to include three new scenarios involving MSA corrections (Section 6.6.4).”^[3] Curiously, as far as the authors have been able to discern, it would appear that there are only two, as opposed to three, updates made to the Event Table in relation to scenarios requiring corrections to previously submitted MSA information.

The first of the two updates is an entirely new entry to the Event Table pertaining to scenarios in which ORM had previously been reported and accepted by CMS where it is determined that TPOC and MSA information, which had been previously submitted along with that ORM coverage, had actually been reported in error. In such scenarios, CMS’s guidance regarding appropriate RRE action involves the submission of a delete record coupled with a new add record which is similar to guidance CMS provides in scenarios where a key field update may be required.^[4] The delete record submission should remove the prior WCMSA and TPOC related information from CMS’s system, while the add record would simply repost the ORM coverage information alone.

The second of the two Event Table updates is a modification to a pre-existing entry relating to scenarios in which non-key field information may need to be updated. In addition to pre-existing guidance related to a handful of longstanding data elements, additional guidance has been added by CMS in relation to changes to the newly introduced MSA Amount field. While the newly added Event Table entry, outlined above, pertains to removal of prior erroneous submission of WCMSA information, the update to this pre-existing entry pertains specifically to scenarios in which the MSA Amount had previously been missing or where an incorrect MSA value had been submitted in which either an MSA Amount value must be newly added or a prior value must be updated to correct a prior incorrect value. In these scenarios, CMS instructs RREs to submit an update record with the correct MSA Amount value.^[5]

CMS “clarification” – TPOC reporting threshold regarding no-fault and WC cases

As part of the Chapter IV updates, CMS states that “[a] clarification has been added that the reporting threshold does apply to non-trauma no-fault and workers’ compensation cases (Section 6.4).”^[6]

In terms of the “clarification,” this relates more specifically to Chapter IV Sections 6.4.2 (No-Fault Insurance TPOCs) and 6.4.4 (Workers’ Compensation TPOCs). As discussed in more detail below, through these updates CMS has removed its prior policy stating that the $750 TPOC reporting threshold did not apply to “alleged ingestion, implantation, or exposure cases” regarding no-fault and workers’ compensations coverages.^[7] Based on CMS’s revised verbiage as outlined below, CMS’s $750 reporting threshold can be interpreted to now also apply to “alleged ingestion, implantation, or exposure cases” whereas, previously, these coverage types were excluded from this reporting threshold.

On this point, CMS’s “clarification” is outlined more fully as follows:

CMS’s prior language included within Chapter IV Sections 6.4.2 (No-Fault Insurance TPOCs) read as follows: “As of January 1, 2025, CMS will maintain the $750 threshold for no-fault insurance, where the no-fault insurer does not otherwise have ongoing responsibility for medicals. This threshold does not apply to non-trauma no-fault reporting for alleged ingestion, implantation, or exposure cases. Any settlement, regardless of amount, should be reported for these types of cases.” (authors’ emphasis).^[8] CMS’s updated language in NGHP User Guide Version 8.0 removes the bolded underlined segment of the above language and now simply reads: “As of January 1, 2025, CMS will maintain the $750 threshold for no-fault insurance, where the no-fault insurer does not otherwise have ongoing responsibility for medicals.”^[9]

Similarly, prior language included within Chapter IV Section 6.4.4 (Workers’ Compensation TPOCs) read: “As of January 1, 2025, CMS will maintain the $750 threshold for workers’ compensation settlements, where the workers’ compensation entity does not otherwise have ongoing responsibility for medicals. This threshold does not apply to non-trauma workers’ compensation reporting for alleged ingestion, implantation, or exposure cases. Any settlement, regardless of amount, should be reported for these types of cases.”(authors’ emphasis)^[10]CMS’s updated language in NGHP User Guide Version 8.0 removes the bolded underlined segment of the above language and now simply reads: “As of January 1, 2025, CMS will maintain the $750 threshold for workers’ compensation settlements, where the workers’ compensation entity does not otherwise have ongoing responsibility for medicals.”^[11]

Thus, based on CMS’s revised verbiage as outlined above, CMS’s $750 TPOC reporting threshold can be interpreted to now also apply to “alleged ingestion, implantation, or exposure cases” for no-fault and workers’ compensation coverages.

Of note, historically, the exact language contained in Chapter IV Sections 6.4.2 and 6.4.4 regarding the $750 TPOC reporting threshold has been duplicated in Chapter III Section 6.4.2 and 6.4.4. However, for reasons unknown, CMS did not apply its “clarification” to the referenced Chapter III sections as part of the Version 8.0 updates. Thus, at present, the information provided in Chapter III on this point directly contradicts the new information CMS added in Chapter IV as part of its Version 8.0 update. Going forward, it will be interesting to see if CMS publishes another subsequent update to resolve this discrepancy.

On another point, CMS’s new “clarification” regarding the $750 TPOC reporting threshold for no-fault and worker’s compensation coverages involving alleged ingestion, implantation, or exposure claims can arguably be classified more accurately as a complete policy change to CMS’s prior guidance in this area and is particularly interesting when considering that CMS had only just updated the prior language in both Sections 6.4.2 and 6.4.4 to provide the exact opposite “clarification” with publication of their NGHP User Guide, Version 7.5 on April 1, 2024. Further, CMS’s update on this point, in the big picture, is the latest in a lengthy recent history of various updates and changes CMS has made in this area as outlined in more detail in the endnote to this sentence for those who may be interested.^[12]

Additional Appendices Updates

As part of the Chapter V updates, CMS states that “[t]o reflect improved reporting requirements, Zip+4 section guidance has been updated (Appendix A, Appendix B, and Appendix G). To ensure consistency of data, as of October 6, 2025, the Recovery Agent TIN field is required if agent name is submitted (Appendix B and Appendix G).”^[13]

In regard to the updated Zip+4 guidance, the changes made within Chapter V Appendices A, B and G all pertain to a change in what CMS is directing RREs to populate in scenarios where the Zip+4 is “not applicable or unknown.”^[14]Prior to these Version 8.0 updates, the description fields for all Zip+4 data elements found within the Claim Input File (Appendix A) and TIN Reference File (Appendix B) layouts, as well as within the Disposition, Error, and Warning Flags (Appendix G) table, indicated, “If not applicable or unknown, fill with zeroes (0000).”^[15] However, with the Version 8.0 updates, these Zip+4 description fields now all indicate, “If not applicable, fill with spaces.”^[16] While this is obviously a change in the direction which CMS had previously provided, based on the present updates, at least from the authors’ perspective, it is unclear whether Zip+4 values populated with zeroes, as opposed to spaces, may cause CMS to return an error on RREs’ response files. These Zip+4 changes appear to be effective as of publication of the current NGHP User Guide (Version 8.0, April 7, 2025).

In relation to the newly updated Recovery Agent TIN guidance, CMS has indicated that, as of October 6, 2025, the Recovery Agent TIN (TIN Reference File field 25) will be required whenever the Recovery Agent Mailing Name (TIN Reference File field 16) is populated. In essence, if an RRE is submitting Recovery Agent information within their TIN Reference File, the Recovery Agent TIN will be required.^[17]CMS has also introduced a new error code (TN41) which the agency will begin to return, once the new requirements take effect, if the Recovery Agent TIN is not populated when the Recovery Agent Mailing Name is populated.^[18] Prior to these newly published updates, the Recovery Agent TIN had only been required in scenarios where an RRE was looking to opt their Recovery Agent into the “go paperless” process via which conditional payment correspondence could be distributed electronically via the MSPRP as opposed to via physical mail. Moving forward, the Recovery Agent TIN will be applicable in any scenario in which Recovery Agent information is being submitted via the TIN Reference File.

Questions?

Please do not hesitate to contact the authors if you have any questions, or to learn more about how Verisk’s Section 111 reporting solutions can help improve your compliance practices.

[1] CMS’s Section 111 NGHP User Guide (Version 8.0, April 7, 2025), Chapters II, III, IV and V (Summary of Version 8.0 Updates), as noted in “Chapter 1” of each of the Chapters referenced.

[2] CMS’s Section 111 NGHP User Guide (Version 8.0, April 7, 2025), Chapter V, Appendix A

[3] CMS’s Section 111 NGHP User Guide (Version 8.0, April 7, 2025), Chapter IV, Section 1 (Summary of Version 8.0 Updates).

[4] CMS’s Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter IV, Section 6.6.4.

[5] CMS’s Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter IV, Section 6.6.4.

[6] CMS’s Section 111 NGHP User Guide (Version 8.0, April 7, 2025), Chapter IV, Section 1 (Summary of Version 8.0 Updates).

[7] CMS’s Section 111 NGHP User Guide (Version 7.9, January 6, 2025), Chapter IV, Sections 6.4.2 and 6.4.4.

[8] CMS’s Section 111 NGHP User Guide (Version 7.9, January 6, 2025), Chapter IV, Section 6.4.2.

[9] CMS’s Section 111 NGHP User Guide (Version 8.0, April 7, 2025), Chapter IV, Section 6.4.2.

[10] CMS’s Section 111 NGHP User Guide (Version 7.9, January 6, 2025), Chapter IV, Section 6.4.4.

[11] CMS’s Section 111 NGHP User Guide (Version 8.0, April 7, 2025), Chapter IV, Section 6.4.4.

[12] On this point, CMS’s “clarification” is particularly interesting when considering that CMS had only recently updated the prior language in both Sections 6.4.2 and 6.4.4 to provide the exact opposite “clarification” with publication of their NGHP User Guide, Version 7.5 on April 1, 2024. Prior to that Version 7.5 update, both Sections 6.4.2 and 6.4.4 had matching language which read: “This threshold does not apply to non-trauma liability reporting for alleged ingestion, implantation, or exposure cases. Any settlement, regardless of amount, should be reported for these types of cases.” (authors’ emphasis)CMS’s Section 111 NGHP User Guide (Version 7.9, January 6, 2025), Chapter V, Appendix A, Appendix B and Appendix G. The prior updated language, which remained intact from Version 7.5 through Version 7.9, had been intended to resolve confusion regarding the bolded underlined word “liability” in the above passage. While this language was present within both the specific sections pertaining to no-fault and workers’ compensation TPOCs, the word “liability” had previously led to questions as to whether or not the $750 threshold should truly not apply to non-physical trauma related no-fault and workers’ compensation TPOCs similar to the way it did not apply to non-physical trauma-based liability TPOCs. With CMS’s updated language initially published in Version 7.5, CMS had clarified that the $750 threshold did not apply to non-physical trauma based no-fault and workers’ compensation TPOCs similar to the way it did not apply to non-physical trauma-based liability TPOCs. CMS’s Section 111 NGHP User Guide (Version 8.0, April 7, 2025), Chapter V, Appendix A, Appendix B and Appendix G. Now, with the current NGHP User Guide Version 8.0, CMS appears to have entirely reversed that prior clarification and the agency is now indicating that the $750 mandatory TPOC reporting threshold does apply even to non-physical trauma based no-fault and workers’ compensation TPOCs and that the only scenario in which that $750 mandatory TPOC threshold does not apply is in non-physical trauma-based liability TPOC scenarios.

[13] CMS’s Section 111 NGHP User Guide (Version 8.0, April 7, 2025), Chapter V, Appendix A, Appendix B and Appendix G.

[14] CMS’s Section 111 NGHP User Guide (Version 8.0, April 7, 2025), Chapter V, Appendix A, Appendix B and Appendix G.

[15] CMS’s Section 111 NGHP User Guide (Version 7.9, January 6, 2025), Chapter V, Appendix A, Appendix B and Appendix G.

[16] CMS’s Section 111 NGHP User Guide (Version 8.0, April 7, 2025), Chapter V, Appendix A, Appendix B and Appendix G.

[17] CMS’s Section 111 NGHP User Guide (Version 8.0, April 7, 2025), Chapter V, Appendix B.

[18] CMS’s Section 111 NGHP User Guide (Version 8.0, April 7, 2025), Chapter V, Appendix G.