CMS releases Section 111 NGHP User Guide (Version 8.3)

By Mark Popolizio, J.D., Jeremy Farquhar

January 6, 2026 / 7 min read

The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 NGHP User Guide (Version 8.3, January 5, 2026) regarding Section 111 reporting related to non-group health plans (NGHPs) (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. In reviewing these pages, CMS indicates that it has made changes to Chapter I (Introduction and Overview), Chapter II (Registration Procedures), Chapter III (Policy), Chapter IV (Technical Information), and Chapter V (Appendices).

CMS S111 User Guide

Summary

As outlined more fully below, CMS notes that it has added what can be described as a small wording update to existing User Guide verbiage to Chapter I (Chapter 6), Chapter II (Chapter 3), and Chapter IV (Chapters 3, 7, and 8.1) to clarify that CMS will return the “most current” Medicare ID as part of the Section 111 Query Response File and Claim Response File records when a match is found. As a practical matter, while CMS has added the above noted language, it is noted that CMS has historically returned the most current assigned Medicare IDs, which the beneficiaries would have received via their most current Medicare cards, via the Query and Claim Response Files. Further, on this point, it is noted that CMS had made prior reference to their providing the “most current” Medicare ID in other sections in prior User Guides. In addition, CMS, as stated in its November 2025 Alert, notes that it is retaining its $750 low dollar threshold (as more specifically defined by CMS below) for 2026. Regarding this update, this is approximately the 10th consecutive year that CMS has retained its “low dollar” threshold at $750. See below regarding CMS’s exact verbiage regarding the applicability (and non-applicability) of the $750 low dollar threshold.

For those interested in a more in-depth overview of User Guide Version 8.3 updates, the authors provide the following overview:

CMS adds clarifying language that it will return the claimant’s “most current” Medicare ID information

CMS’s Summary pages indicate that “[v]erbiage has been added to clarify that a member’s most current Medicare ID will be provided when a match is found” to Chapters I (Chapter 6), II (Chapter 3), and IV (Chapters 3, 7, and 8.1).^[1]As outlined below, CMS updated existing language in the above noted chapters by adding the words “most current” to indicate that CMS will return the “most current” Medicare ID.

This update relates to the information CMS returns as part of both the Section 111 Query Response File and Claim Response File Records. As many are likely aware, CMS as part of its Query response provides the RRE with the following information when an individual has been identified as a Medicare beneficiary: Part A and B entitlement dates, as well as Part C (Medicare Advantage Plan) and Part D (Medicare prescription drug coverage) enrollment information for the past 3 years (up to 12 instances).^[2]In addition to this information, CMS also provides information regarding the claimant’s Medicare ID through the Query response. Regarding the Medicare ID, CMS has now added verbiage to existing language in Chapters I (Chapter 6), II (Chapter 3), and IV (Chapters 3, 7, and 8.1) indicating that it will provide RREs with “the most current Medicare ID (and other updated information for the individual) found on the Medicare Beneficiary Database (MBD)”^[3](authors emphasis). By way of comparison, the prior User Guide language for these specific chapters did not contain the words “most current.” Rather, CMS’s prior verbiage simply stated that CMS would “provide the Medicare ID (and other updated information for the individual) found on the Medicare Beneficiary Database (MBD).”^[4]Of note, as referenced above, while CMS has added this verbiage to the above cited Chapters as part of the Version 8.3 updates, CMS had made prior reference to their providing the “most current” Medicare ID in other sections in prior User Guides.^[5]

In addition to the clarification related to the Query Response File outlined above, CMS has also added clarifying language to the description of field 16 (Applied Injured Party Medicare ID) within the Claim Response File layout (Appendix C) located in Chapter V (Appendices). Here, within the Description field CMS has added new verbiage indicating “[i]f no match is found for a member’s most current Medicare ID, the position will be filled with spaces.”^[6]

In the big picture, these updates would appear to be minor clarifications to CMS’s NGHP User Guide language and not indicative of any substantive changes to CMS’s longstanding processes. Specifically, as a practical matter, CMS has historically always returned the most current assigned Medicare IDs, which the beneficiaries would have received via their most current Medicare cards, via the Query and Claim Response Files. Furthermore, in scenarios where a Claim Detail Record is submitted via the Claim Input File for which a positive beneficiary match is not identified, CMS has always returned spaces in the ”Applied Injured Party Medicare ID” field as there would have been no information actually applied at all to CMS’s internal systems when a non-matching beneficiary (‘51’ disposition) response was returned to the RRE.

$750 Low Dollar Threshold (2026)

CMS states as follows in its Chapter III Summary updates: “As of January 1, 2026, CMS will maintain the $750 threshold for no-fault insurance, where the no-fault insurer does not otherwise have ongoing responsibility for medicals (Sections 6.4.2, 6.4.3, and 6.4.4).”

As will be noted above, CMS references retention of its $750 low dollar threshold for “no-fault” claims. However, it is noted that in November 2025 CMS issued an Alert advising it was retaining its $750 low dollar threshold (as specifically defined by CMS) in 2026 for no-fault, liability, and workers’ compensation claims. Specifically, CMS’s Alert itself is titled “Recovery Thresholds for Certain Liability Insurance, No-Fault Insurance, and Workers’ Compensation Settlements, Judgments, Awards or Other Payments.”

Thus, the authors are uncertain why CMS only references “no-fault” claims in its Summary page as noted above. From the authors view, this is likely a simple oversight on CMS’s behalf, especially since the applicable User Guide sections cited by CMS (Sections 6.4.2, 6.4.3, and 6.4.4) all reflect that the $750 low dollar threshold remains applicable for no-fault, liability, and worker’s compensation TPOCs. Of note, CMS has maintained the $750 low dollar threshold for the past 10 consecutive years.

To avoid any potential confusion here, the authors note that CMS states as follows in its User Guide regarding its $750 low dollar threshold:

No-Fault TPOCs

CMS states in pertinent part: “As of January 1, 2026, 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.” CMS’s Section 111 NGHP User Guide (Version 8.3, January 5, 2026), Chapter III, Section 6.4.2.

Liability Insurance (including self-insurance) TPOCs

CMS states in pertinent part: “As of January 1, 2026, the threshold for physical trauma-based liability insurance settlements will remain at $750. 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.” CMS’s Section 111 NGHP User Guide (Version 8.3, January 5, 2026), Chapter III, Section 6.4.3.

Workers’ Compensation TPOCs

CMS states in pertinent part: “As of January 1, 2026, 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.” CMS’s Section 111 NGHP User Guide (Version 8.3, January 5, 2026), Chapter III, Section 6.4.4.

From a practical perspective, RREs should carefully review CMS’s above verbiage to understand to which claims the $750 low dollar threshold applies and does not apply.

Questions?

Please do not hesitate to contact the authors if you have any questions or would like to learn more about how Verisk can help you with Section 111 reporting.

[1] CMS’s Section 111 NGHP User Guide (Version 8.3, January 5, 2026), Chapter I, Chapter: 1: Summary of Version 8.3 Updates; Chapter II, Chapter 1: Summary of Version 8.3 Updates; and Chapter IV, Chapter 1: Summary of Version 8.3 Updates.

[2] CMS’s Section 111 NGHP User Guide (Version 8.3, January 5, 2026), Chapter II, Chapter 3. See also, CMS’s Section 111 NGHP User Guide (Version 8.3, January 5, 2026), Chapter IV, Chapters 3, 7, and 8.1.

[3] CMS’s Section 111 NGHP User Guide (Version 8.3, January 5, 2026), Chapter II, Chapter 3.

[4] On this point, by way of example, the prior version of Chapter II, Chapter 3 read, in pertinent part, as follows:

“On the query response record, the BCRC will provide information on whether the individual has been identified as a Medicare beneficiary based upon the information submitted and if so, provide the Medicare ID (and other updated information for the individual) found on the Medicare Beneficiary Database (MBD). Beneficiary Part C (Medicare Advantage Plan) and Part D (Medicare prescription drug coverage) enrollment information will be provided for the past 3 years (up to 12 instances), as well as the most recent Part A and Part B entitlement dates.” CMS’s Section 111 NGHP User Guide (Version 8.2, January 5, 2026), Chapter II, Chapter 3.

As part of the User Guide Version 8.3 updates, CMS has added the words “most current” to the above language with the updated language now reading as follows:

“On the query response record, the BCRC will provide information on whether the individual has been identified as a Medicare beneficiary based upon the information submitted and if so, provide the most current Medicare ID (and other updated information for the individual) found on the Medicare Beneficiary Database (MBD). Beneficiary Part C (Medicare Advantage Plan) and Part D (Medicare prescription drug coverage) enrollment information will be provided for the past 3 years (up to 12 instances), as well as the most recent Part A and Part B entitlement dates.” (authors emphasis). CMS’s Section 111 NGHP User Guide (Version 8.3, January 5, 2026), Chapter II, Chapter 3.

Of note, as part of User Guide Version 8.3, CMS also added the phrase “most current” to CMS’s Section 111 NGHP User Guide (Version 8.3, January 5, 2026), Chapter I, Chapter 6 and Chapter IV, Chapters 3, 7, and 8.1 as follows:

Per the above, updated Chapter I, Chapter 6 reads, in pertinent part: “On the query response record, the BCRC will provide information on whether the individual has been identified as a Medicare beneficiary based upon the information submitted and, if so, provide the most current Medicare ID (and other updated information for the individual) found on the Medicare Beneficiary Database.” (Version 8.3, January 5, 2026), Chapter I, Chapter 6).

Updated Chapter IV, Chapter 3 reads, in pertinent part: “On the query response record, the BCRC will provide information on whether the individual has been identified as a Medicare beneficiary based upon the information submitted and, if so, provide the most current Medicare ID (and other updated information for the individual) found on the Medicare Beneficiary Database.” CMS’s Section 111 NGHP User Guide (Version 8.3, January 5, 2026), Chapter IV, Chapter 3).

Updated Chapter IV, Chapter 7 reads, in pertinent part: “If the BCRC can match the injured party identified by the RRE to a Medicare beneficiary, based upon the information submitted on the input record, the response record will always contain the most current Medicare ID (HICN or MBI) for that individual. You must save the Medicare ID returned for Medicare the beneficiary and use it on any subsequent Claim Input File records for that beneficiary. The Medicare ID is CMS’ official beneficiary identifier, and is always the preferred data element for use in matching your information to Medicare beneficiaries.” (Version 8.3, January 5, 2026), Chapter IV, Chapter 7).

Finally, updated Chapter IV, Chapter 8.1 reads, in pertinent part: “If a match is found, you will always be returned the most current Medicare ID for the individual you are querying on. You must store this Medicare ID on your internal files and use it on future Claim Input File transactions. This is CMS’ official identifier for the beneficiary, and it will be used by the BCRC when matching claim records to Medicare beneficiaries.” (Version 8.3, January 5, 2026), Chapter IV, Chapter 8.1).

[5] On this point, for example, in User Guide Version 8.2, in Section 6.1.1 CMS states: “While Medicare IDs may be changed at times (but only by the Social Security Administration [SSA]), the BCRC is able to crosswalk an old Medicare ID to the new Medicare ID. The BCRC will always return the most current Medicare ID on response records, and RREs are to update their systems with that information and use it on subsequent record transmissions. However, updates and deletes sent under the original Medicare ID/SSN will still be matched to the current Medicare ID.” (authors emphasis). CMS’s Section 111 NGHP User Guide (Version 8.2, October 6, 2025). Similar references to the “most current” Medicare ID being returned are noted in User Guide Version 8.2, Sections 6.6.2 and 6.6.4.

[6] CMS’s Section 111 NGHP User Guide (Version 8.3, January 5, 2026), Chapter V, Chapter 1: Summary of Version 8.3 Updates.