CMS’s Section 111 NGHP Unsolicited Response File “opt-in” process

By Mark Popolizio, J.D., Jeremy Farquhar

June 27, 2023 / 5 min read

The Centers for Medicare and Medicaid Services (CMS’s) Section 111 NGHP Unsolicited Response File “opt-in” process starts July 2023. The following “Nutshell Summary” is a general summary of this process based on information provided by CMS as of the date this summary was prepared.

Of note, this “Nutshell Summary” resource is intended as a secondary resource to be used in conjunction with the more detailed overviews provided in the authors’ recent article Unsolicited Response File “Question & Answer” article and CMS’s recent Section 111 NGHP User Guide (Version 7.2, June 5, 2023).

cms section

With the above noted, the following general overview is provided:

Process Basics

Starts July 2023
CMS will accept an ORM termination date from the beneficiary, or their authorized representative
The BCRC Call Center will be used to accept this information and change the RRE’s ORM records
RREs will be allowed to either update their own internal data or contact the BCRC for a correction
Optional process – but CMS has urged RREs to opt-in and participate in this process
Process only available for file submitters – not available for Direct Data Entry (DDE) reporters
RREs who “opt-in” will receive a monthly NGHP Unsolicited Response File which will provide information about updates to ORM records originally submitted in the last 12 months
For more information, see Q/As # 1-3 and 5-7 in the authors’ recent article.

RRE “opt-in” for new RRE registrations

Ability to opt in will be added to the Account Setup portion of the registration process via CMS’s Section 111 COBSW.
Registrants will see a newly added question asking, “Would you like to receive Unsolicited Alerts?” followed by the statement, “Check here to receive Unsolicited Alerts” coupled with a radio button which may be selected by the registrant to opt in.
RRE’s Account Manager (AM) should opt an RRE into the Unsolicited Response File process
For more information, see Q/A # 4 in the authors’ recent article.

RRE “opt-in” for existing RRE accounts

RREs can opt in via the Section 111 COBSW.
Beginning in July, RREs will have the ability to opt into the process via the RRE ID Profile Information screen where they will see a new radio button which may be selected to participate in the new process.
RRE’s Account Manager (AM) should opt an RRE into the Unsolicited Response File process
For more information, see Q/A # 4 in the authors’ recent article.

Information CMS will accept

CMS will only accept an ORM termination date from the beneficiary, or their authorized rep
The beneficiary, or their authorized rep, will NOT be able to delete the ORM coverage record
CMS will refer the beneficiary, or their authorized rep, to the Section 111 RRE regarding any other requests to update the RREs Section 111 records
For more information, see Q/A # 4 in the authors’ recent article.

How CMS will return the Unsolicited Response File

The Unsolicited Response File will be made available on the 2^nd Sunday of each calendar month and the files will be returned via the same transmission method already utilized for each RRE’s other response files.
Regarding the information CMS will return, see, CMS’s Section 111 NGHP User Guide (Version 7.2, June 5, 2023), Chapter V, Appendix F. Click here to view Appendix F.
For more information, see Q/A # 9 in the authors’ recent article.

Inaccurate information

In situations where the RRE identifies inaccurate information on the Unsolicited Response File, CMS has advised that the RRE should submit a correction on their next subsequent Section 111 file.
For more information, see Q/A # 10 and 11 in the authors’ recent article.

Conditional Payments

Per CMS, updates made to the Section 111 ORM coverage records through this process will not directly impact conditional payment recovery cases or processes
CMS has advised that this process will not replace the letters that the BCRC currently mails out to RREs when an ORM Termination Date has been reported by a beneficiary or their authorized representative.
For more information, see Q/A # 12 in the authors’ recent article.

Unsolicited Response File record layout

See CMS’s Section 111 NGHP User Guide (Version 7.2, June 5, 2023), Chapter V, Appendix F for information on the Unsolicited Response File record layout
For an overview of which fields CMS has recently removed, and which fields remain, as part of the file layout, see Q/A # 13 in the authors’ recent article.

What information will CMS relay via the Modifier Type Code and Change Reason Code fields?

See CMS’s Section 111 NGHP User Guide, Version 7.2 (June 5, 2023), Chapter IV, Section 7.5, Tables 7-3 and 7-4 respectively for a current list of valid Modifier Type Code and Change Reason Code values.
For a general overview regarding key aspects related to the Modifier Type and Change Reason codes, see Q/A # 14 in the authors’ recent article.

File Naming Conventions

CMS has provided updated information regarding file name formats as part of CMS’s Section 111 NGHP User Guide (Version 7.2, June 5, 2023), Chapter IV, Section 10.2 for those RREs utilizing a Connect: Direct file transmission method.
For more information, see Q/A # 15 in the authors’ recent article.

Special note for Verisk Section 111 reporting customers

Please note that for customers reporting through one of Verisk's S.111 reporting solutions, you will be able to view and/or intake the new file and trigger a claim to be resubmitted for correction, even if no updates have been made by the RRE. Further specifics regarding Verisk’s updated processes will follow for our customers. If you are not a current Section 111 reporting customer but would like more information about our Section 111 reporting solution, MSP Navigator, please do not hesitate to contact us at support@mspnavigator.com.

Questions?

Please contact the authors if you have any questions regarding the above or CMS’s Section 111 NGHP Unsolicited Response File “opt-in” feature in general.