CMS Releases Section 111 NGHP User Guide (Version 8.4)

By Mark Popolizio, J.D., Jeremy Farquhar

April 20, 2026 / 12 min read

The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 NGHP User Guide (Version 8.4, April 13, 2026) regarding Section 111 reporting related to non-group health plans (NGHPs) (liability, no-fault and workers’ compensation.)

From the authors’ perspective, CMS’s updates vary in terms of significance and potential impact. On the one hand, CMS has added some clarifying verbiage regarding ORM termination and a minor verbiage update to the TPOC date. Similarly, CMS notes added EDI Rep. contact functionality and has made a minor update to the Unsolicited Response File “Change Reason Description” table. On the other hand, CMS has made more notable updates in other areas. For example, in situations where there is a single settlement with multiple defendants (RREs) and one MSA, CMS is now instructing that each RRE reports the full MSA value (and not just the amount they have contributed to the overall MSA) which is a change from CMS’s recently published guidance in User Guide (Version 8.2). Another potentially notable change relates to new updates regarding wrongful death settlements as discussed more fully below.

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These updates, and others, are outlined as follows:

Summary of Version 8.4 Updates

A general update of CMS’s changes includes:

ORM termination: CMS added clarifying verbiage to existing language that ORM may be terminated “for any reason that is not prohibited by the terms of the insurance contract or applicable state or federal law” and that “[a]n insurer’s refusal to accept ORM, or to continue to accept ORM, is a valid ORM termination reason, provided that the refusal is permitted by applicable state or federal law and the terms of the insurance contract.”
TPOC date: CMS has added the phrase “or commission” in all places where the long-standing phrase “unless court approval is required” appears with respect to defining the TPOC date. For example, with respect to defining the TPOC date in relation to a written agreement, CMS’s update verbiage reads: “This is the date the obligation is signed if there is a written agreement, unless court or commission approval is required. If court or commission approval is required, it is the later of the date the obligation is signed or the date of court or commission approval.”
Wrongful death settlements: CMS has added new verbiage noting that the RRE must provide CMS, in the context of a recovery dispute or appeal, with certain documentation showing what was claimed or released, or the settlement had the effect of releasing, along with a citation to specific state statutes or case law that precludes recovery from a wrongful death settlement. In addition, CMS has removed some long-standing verbiage from this section. CMS’s updates in this area may potentially signal CMS’s intent to have wrongful death settlements reported, which would be a significant departure from its historical guidance.This is an area that likely requires additional clarification and explanation from CMS going forward.
Multiple TPOCs submitted for the same individual, for the same incident, but reported by different RREs – RREs report their “unique” TPOC amount (and not aggregate TPOC amount) in scenarios where there is proportionate or several liability (not joint and several liability). These instructions are similar to previous CMS guidance in these scenarios.
Multiple defendants (RREs), single settlement, one MSA (NEW guidance) – Each RRE reports the total MSA amount (not their proportionate share contributed to the MSA). This update changes how CMS instructed RREs to report the MSA in these scenarios from what they stated in User Guide, Version 8.2 released last November. Thus, regardless of how the RRE must report the TPOC amount per CMS’s TPOC reporting rules (either their proportionate share to a settlement, or the total aggregate settlement amount), when it comes to reporting the MSA, they must report the full MSA amount (and not just what they may have contributed to the MSA) based on this new update.
Added EDI Rep. Contact Functionality: CMS has added new functionality to its Section 111 COB Secure Website (COBSW), which allows RREs to contact their assigned EDI Representatives directly via the COBSW as opposed to sending an email or placing a phone call.
Unsolicited Response File “Change Reason Description” Table updates: CMS has removed the “(As of April 2026)” text from the Description field regarding the “AO” (“added occurrence”) and “SP” (“SP error correction”) codes.

For those interested, the authors provide additional details regarding each of the above points as follows:

ORM termination - additional clarifying language

CMS has updated Chapter III, Section 6.3.2 with what can be viewed as additional clarifying language regarding ORM termination. Specifically, to the long-standing language in this section, CMS has now added language stating that ORM termination is applicable, or appropriate, if the RRE has “any other reason that is not prohibited by the terms of the insurance contract or applicable state or federal law.”^[1]Further, CMS has added a “note” in this section stating that “[a]n insurer’s refusal to accept ORM, or to continue to accept ORM, is a valid ORM termination reason, provided that the refusal is permitted by applicable state or federal law and the terms of the insurance contract.”^[2]

With these changes, Section 6.3.2, as modified by CMS’s updates, now reads, in pertinent part, as follows, with the new verbiage noted in “bold:” “Where the insurer’s responsibility for ORM has been terminated per the terms of the pertinent insurance contract, such as maximum coverage benefits, or any other reason that is not prohibited by the terms of the insurance contract or applicable state or federal law. Note: An insurer’s refusal to accept ORM, or to continue to accept ORM, is a valid ORM termination reason, provided that the refusal is permitted by applicable state or federal law and the terms of the insurance contract.” CMS’s NGHP User Guide, Version 8.4, Chapter III, Section 6.3.2 (author’s emphasis).

TPOC “date” - additional (and minor) clarifying language

CMS has also added what can be viewed as minor clarifying language to the TPOC “date” in the context of a written agreement, as noted in Chapter III, Sections 6.4 and 6.5.1.2. Specifically, in Section 6.4 CMS has added “or commission” in all places where “unless court approval is required” previously appeared. A similar change was made to Section 6.5.1.2 regarding the timeliness of reporting. Sections 6.4 and 6.5.1.2, as amended, in pertinent part, by the new updates, are restated in the endnote to this sentence.^[3]

Wrongful Death Settlements – new updates and documentation requirements

CMS has made what may be viewed as a potentially significant change to its reporting guidance regarding wrongful death settlements as outlined in Chapter III, Section 6.5.1.4.

Specifically, CMS’s longstanding guidance stated that TPOCs obtained entirely under the wrongful death theory of liability, which did not claim and release medicals, or have the effect of releasing medicals, were not reportable because Medicare would have no recovery claim against such a payment.^[4]

Furthermore, CMS noted this guidance during the Q&A Segment of its September 12, 2024, NGHP Reporting Best Practices webinar, in the feedback it gave in response to a question it received regarding “What is the best way to report a strictly wrongful death case to Medicare under S111?” In response, CMS stated that if medicals were not claimed and released, then there is no need to report the settlement since Medicare would have no right to recover where medical expenses were not contemplated, included, settled, or otherwise released. On the other hand, if medicals were claimed and released, then reporting is necessary, even if the claim was entirely for wrongful death and was appropriately allocated.^[5]

Against this backdrop, CMS’s new Version 8.4 updates make some notable changes. In this regard, it is noted that CMS has now removed its longstanding verbiage as stated above and has replaced it with verbiage noting that the RRE must provide CMS, in the context of a recovery dispute or appeal, with certain documentation showing what was claimed or released, or the settlement had the effect of releasing, along with a citation to specific state statutes or case law that precludes recovery from a wrongful death settlement.

More specifically, on these points, the new updates to Section 6.5.1.4 state as follows:

In order for the wrongful death theory of liability to preclude Medicare from recovering from a settlement, judgment, award, or other payment, complete documentation must be provided that shows what was claimed and released or had the effect of being released. Additionally, a citation to the appropriate state statute or case law that precludes recovery from a wrongful death settlement should be included with any such dispute or appeal. CMS’s NGHP User Guide, Version 8.4, Chapter III, Section 6.5.1.4.

CMS’s new updates provided no additional information regarding actual reporting. However, given that CMS has removed its long-standing language and has replaced it with the new verbiage quoted above, this update may suggest that CMS now expects RREs to report a wrongful death settlement regardless of whether medicals had been claimed, released, or the settlement had the effect of releasing medicals. If this is, in fact, CMS’s intent, then this would be a significant departure from its prior, longstanding published guidance. From the authors’ perspective, it is unclear what may have prompted CMS’s apparent change of direction regarding these scenarios, but this does appear to be a potentially notable change which requires additional clarification and explanation from CMS going forward.

Multiple TPOCs submitted for the same individual, for the same incident, but reported by different RREs – RREs report their “unique” TPOC amount in scenarios where there is proportionate or several liability (not joint and several liability)

CMS has added some clarifying language regarding scenarios where there are multiple settlements regarding the same individual and different RREs in Chapter III, Section 6.5.1.3. Specifically, CMS has added language to this section clarifying that in these scenarios where there is not joint and several liability, then each RRE reports their own “unique” TPOC amount – and not the aggregate amount the claimant will receive. These instructions are similar to previous CMS guidance in these scenarios.

On this point, CMS states as follows, with the new verbiage in bold: “Multiple settlements involving the same individual – If there will be multiple TPOCs submitted for the same individual, for the same incident, but reported by different RREs (proportionate or several liability but not joint and several), the records shall reflect each RRE’s unique TPOC amount and not the aggregate TPOC the beneficiary will be receiving. If more than one RRE has assumed responsibility for ongoing medicals, Medicare would be secondary to each such entity.” CMS’s Section 111 NGHP User Guide (Version 8.4, April 13, 2026), Chapter III, Section 6.5.1.3.

Multiple defendants (RREs), single settlement, one MSA – each RRE reports the total MSA amount, and not the proportionate share they contributed to the MSA.

As part of the Version 8.4 updates, CMS has clarified that in scenarios where a settlement involves multiple defendant RREs and one MSA, each RRE reports the total MSA amount (and not their proportionate share).

On this point, CMS states as follows in Chapter III, Section 6.5.1.3: “Where there are multiple defendants (RREs) reporting each RRE must report the total MSA Amount—not just its assigned or proportionate share. System logic exists such that only the first reported MSA amount will be applied for purposes of coordination of benefits.” CMS’s Section 111 NGHP User Guide (Version 8.4, April 13, 2026), Chapter III, Section 6.5.1.3.

Of note, this update changes how CMS instructed RREs to report the MSA in these scenarios from what they stated in User Guide, Version 8.2 released last November. CMS’s prior guidance in Versions 8.2 and 8.3 indicated that the MSA should be reported similarly to how the TPOC was reported.^[6]

Thus, with this new update, regardless of how the RRE must report the TPOC amount (either their proportionate share to a settlement, or the total aggregate settlement amount), when it comes to the MSA, they must report the full MSA amount (and not just what they may have contributed to the MSA) based on this new update.

EDI Representative Contact Functionality Added to the Section 111 COB Secure Website (COBSW)

CMS has added new functionality to its Section 111 COB Secure Website (COBSW), which now allows RREs to perform outreach to their assigned EDI Representatives directly via the COBSW as opposed to sending an email or placing a phone call.^[7]Users should see the new option labeled “View/Submit EDI Request” under “Actions” towards the right-hand side of the RRE Information Detail screen. Upon clicking on this new option, the user will be taken to a screen where a drop-down menu allows for selection of a “Request Type” (“Delete File”, “Release File” or “Other”) along with a freeform text “Description” field via which the user can type their message to the assigned EDI Representative.

Updates to Unsolicited Response File “Change Reason Description” Table

As some readers may likely recall, as part of CMS’s NGHP User Guide Version 8.2 (October 6, 2025), the agency introduced two new Change Reason Codes to their Change Reason Description table (Chapter IV, Table 7-4).^[8] These codes were “AO” referring to an “added occurrence” and “SP” referring to “SP error correction.”

With the new Version 8.4 updates, CMS has simply removed the “(As of April 2026)” text from the Description field for both of these new codes.^[9] While this is hardly a noteworthy update, in and of itself, the authors remain puzzled by the inclusion of these two new codes.

On this point, as discussed in greater detail in our prior article, CMS releases Section 111 NGHP User Guide (Version 8.2), from the authors’ perspective, these new codes do not appear to make sense in the context of the Unsolicited Response File process. As noted in our prior article, the sole purpose of CMS’s Unsolicited Response File is to inform RREs when CMS has applied manual updates to coverage records that the RRE had previously submitted electronically via the Section 111 process. Neither the “AO” nor “SP” Change Reason Codes would appear to have any relation to updates that may be applied to a coverage record which was previously submitted via the Section 111 process. “AO” appears to refer to the addition of a new coverage record (CMS refer to coverage records as ‘occurrences’ and this is the language they’ve used here) and “SP” refers to a correction to a coverage record which had been rejected with errors.^[10]Neither a newly added coverage record, nor a record with errors would be a scenario where the RRE had previously successfully reported coverage to CMS via the Section 111 process. Therefore, as these codes would not refer to coverage records previously successfully submitted by an RRE through the Section 111 process, the authors remain puzzled by their inclusion. It remains to be seen whether CMS will offer any further explanation in this respect going forward.

Questions?

Please do not hesitate to contact the authors if you have any questions regarding the above, or how Verisk can help you with your Section 111 reporting obligations.

[1] CMS’s Section 111 NGHP User Guide (Version 8.4, April 13, 2026), Chapter III, Section 6.3.2.

[2] Id.

[3] Section 6.4, in pertinent part, has been updated to read as follows, with added language in bold:

The TPOC Date is not necessarily the payment date or check issue date. The TPOC Date is the date the payment obligation was established. This is the date the obligation is signed if there is a written agreement, unless court or commission approval is required. If court or commission approval is required, it is the later of the date the obligation is signed or the date of court or commission approval. If there is no written agreement, it is the date the payment (or first payment if there will be multiple payments) is issued. Example: The parties to a workers’ compensation case execute an agreement regarding the claim on 01/20/2026. The state requires the workers’ compensation commission to approve the final settlement details and said approval occurs on 02/05/2026. The TPOC date in this situation would be 02/05/2026 because it is the later of the date the agreement was fully executed and the date the court or commission approved the agreement. CMS’s Section 111 NGHP User Guide (Version 8.4, April 13, 2026), Chapter III, Section 6.4 (author’s emphasis).

Section 6.5.1.2, in pertinent part, has been updated to read as follows:

NGHP TPOC payments are reportable once all of the following criteria are met: • The alleged injured/harmed individual to whom or on whose behalf payment will be made has been identified. • The TPOC amount for that individual has been determined. • The RRE knows when the TPOC will be funded or disbursed to the individual or their representative(s) and any applicable court or commission approval has been obtained. RREs should retain documentation establishing when these criteria were or will be met. RREs should not report the TPOC until the RRE establishes when the TPOC will be funded or disbursed and court or commission approval, if applicable, is obtained. In some situations, funding or disbursement of the TPOC may not occur until well after the TPOC Date. RREs may submit the date the TPOC will be funded or disbursed in the corresponding Funding Delayed Beyond TPOC Start Date field when they report the TPOC Date and TPOC Amount but must do so if the TPOC Date and date of the funding of the TPOC are 30 days or more apart. Timeliness of MMSEA Section 111 reporting for a Medicare beneficiary will be based upon the latter of the TPOC Date, the Funding Delayed Beyond TPOC Start Date, and the court or commission approval date (if applicable). CMS’s Section 111 NGHP User Guide (Version 8.4, April 13, 2026), Chapter III, Section 6.5.1.2 (author’s emphasis).

[4] See e.g., “Settlements, judgments, awards, or other payments obtained entirely under the wrongful death theory of liability, which do not claim and release medicals, or have the effect of releasing medicals, are not required to be reported because Medicare would have no recovery claim against such a payment.” CMS’s Section 111 NGHP User Guide (Version 8.3, January 5, 2026), Chapter III, Section 6.5.1.4.

[5] CMS’s Non-Group Health Plan (NGHP) Section 111 Reporting Webinar (September 12, 2024), Questions and Answers page 3.

[6] On this point, Chapter III, Section 6.5.1.3, as contained in the User Guide (Version 8.3) stated: “As it relates to multiple dates of incident, an MSA, if applicable, shall be reported under the same guidance as above. That is, the earliest date of incident, if only one TPOC is made. If multiple TPOCs are submitted, but only one MSA is reported, the MSA shall be reported on the first TPOC only. Where there are multiple defendants (RREs) reporting in this scenario, the same guidance applies to MSAs as it does to TPOCs.” CMS’s Section 111 NGHP User Guide (Version 8.3, January 5, 2025), Chapter III, Section 6.5.1.3.

[7] CMS’s Section 111 NGHP User Guide (Version 8.4, April 13, 2026), Chapter I, Sections 7 and 8, Chapter II, Sections 6 and 7.1, and Chapter IV, Section 12.

[8] CMS’s Section 111 NGHP User Guide (Version 8.2, October 6, 2025), Chapter IV, Table 7-4.

[9] CMS’s Section 111 NGHP User Guide (Version 8.4, April 13, 2026), Chapter IV, Table 7-4.

[10] Id.