New NGHP Section 111 User Guide (6.4) – PAID Act, ORM termination, and other updates

By Mark Popolizio, J.D., Jeremy Farquhar, Sid Wong, J.D.

June 11, 2021 / 13 min read

The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 NGHP User Guide (Version 6.4, June 11, 2021) regarding non-group health plans (liability, no-fault and workers’ compensation). This updated guide replaces Version 6.3 (April 5, 2021). CMS has also released a related Technical Alert [1] as part these updates. In addition, CMS has released updates to the MMSEA X12 270-271 Companion Guide.

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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 Procedures), Chapter III (Policy Guidance); Chapter IV (Technical Guidance); and Chapter V (Appendices).

In general, the new User Guide contains several different updates, including much anticipated information on how CMS plans to implement the Provide Accurate Information Directly (PAID) Act. CMS notes that its PAID Act implementation plans will not become effective until December 11, 2021.[2] Other key updates were made to CMS’s ORM termination guidelines.

A general overview of these and other updates made by CMS in User Guide (Version 6.4), along with the authors’ observations, is provided as follows:

PAID Act – Query response file and HEW wrapper updates (changes effective 12/11/21)

As noted, many in the industry have been eagerly awaiting CMS guidance and information regarding PAID Act implementation. By way of background, the PAID Act, in general, requires CMS to expand the Section 111 Query Process to (i) identify whether a claimant subject to the query is, or during the preceding 3-year period has been, entitled to benefits under the Medicare program; and if so, (ii) CMS must provide the RRE with the plan name and address of any Medicare Advantage plan under Part C and any prescription drug plan under part D in which the claimant is enrolled or has been enrolled during such period.[3]

In acknowledging the PAID Act, CMS states:

In 2020, the [PAID Act] was passed to help [NGHP RREs] better coordinate benefits by providing additional beneficiary enrollment information. With this Act, RREs will receive Part C (Medicare Advantage Plan) and Part D (Medicare prescription drug coverage) enrollment information for the past 3 years.[4]

To help implement the PAID Act, CMS notes that it will be updating the Query Response file and HIPAA Eligibility Wrapper Software (HEW) as follows:

Query Response File – The Query Response File will be updated to include: Contract Number, Contract Name, Plan Number, Coordination of Benefits (COB) Address, and Entitlement Dates for the last three years (up to 12 instances) of Part C and Part D coverage.

The updates will also include the most recent Part A and Part B entitlement dates.[5]

HEW wrapper software -- The HEW software will also be modified to extract the additional fields from the response file. Finally, process steps for installing and configuring the HEW software will be provided (see chapter V, HEW Query Response File Record and HEW Query Response File Record – Version 4.0.0 and Appendix K).[6] CMS plans to release Version 5.0.0 of the HEW Software on September 13, 2021 and RREs will be able to utilize the new version of the translator software for testing purposes between September 13, 2021 and December 10, 2021.[7]

Importantly, as noted above, CMS’s PAID Act updates will not become effective until December 11, 2021.[8] This is a reminder that CMS is holding a PAID Act webinar on June 23^rd where the agency is expected to further discuss its PAID Act implementation plans.

PAID Act - comments

Regarding CMS’s PAID Act implementation plans outlined above, the authors’ observations include:

Information to be provided:

It is noted that CMS plans to provide more information than is technically required under the PAID Act. Specifically, the PAID Act only requires that CMS provide “the plan name and address” of any identified Medicare Advantage or Part D plan. However, as noted, CMS also plans to provide the contract number, contract name, plan number, and the plan’s COB address. Having this additional information may prove helpful in terms of following up with the identified plan(s) to obtain and address any recovery claims. In addition, CMS is planning to include the most recent Part A and Part B effective and termination dates. Historically, Part A and B coverage dates have never been provided for NGHP entities and their inclusion should provide even greater clarity in terms of overlapping coverage and aid further in terms of appropriate coordination of benefits.

Limitations:

Also, CMS will be limiting the number of distinct Part C and D coverage periods being returned to “12 instances.” This is likely due, in part, to file size restrictions coupled with the unlikely occurrence of a Medicare beneficiary having more than 12 different coverage enrollment periods over a three-year time span.

File Formatting:

It is noted that data elements being returned within the pre-existing response file format will remain populated within the same data positions while the new data elements will simply be added on to the tail end of the record layout.[9]

For more information on the PAID Act, see our companion article CMS releases its PAID Act implementation plans – what’s next and how ISO CP can help

ORM termination updates

Another significant change made in the new User Guide relates to CMS’s ORM termination rules as outlined in Chapter III, Section 6.3.2. Specifically, CMS has added new situations where an RRE may be permitted to file an ORM termination report.

Specifically, Section 6.3.2, in pertinent part, has been updated as follows -- with CMS’s new directives bolded for easier reference:

An ORM termination date should not be submitted as long as the ORM is subject to reopening or otherwise subject to an additional request for payment. An ORM termination date should only be submitted if one of the following criteria has been met:

Where there is no practical likelihood of associated future medical treatment, an RRE may submit a termination date for ORM if it maintains a statement (hard copy or electronic) signed by the beneficiary’s treating physician that no additional medical items and/or services associated with the claimed injuries will be required;
Where there is no practical likelihood of associated future medical treatment, which is reflected by meeting ALL of the following:
- No claims were paid with any diagnoses codes related to alleged ingestion, implantation, or exposure; and
- No claims were paid, for any medical item or service related to the case, within five (5) years of the date of service of any such claim; and
- Treatment did not include, nor were any claims paid related to, a medical implantation or prosthetic device; and
- The total amount paid by the insurer, for all medical claims related to the case, did not exceed $25,000.
- Note: If, at any time, any of the parameters set forth above should no longer be applicable, the insurer must then update the ORM record to reflect that they, once again, have ongoing responsibility for medicals (i.e., update the termination date to all zeroes). Should the case once again fall under these parameters (for example, if five years elapse from the last relevant date of service), then ORM for that case may once again be terminated in accordance with the criteria

Where the insurer’s responsibility for ORM has been terminated under applicable state law associated with the insurance contract;
Where the insurer’s responsibility for ORM has been terminated per the terms of the pertinent insurance contract, such as maximum coverage [10]

ORM termination - comments

In assessing CMS’s additional ORM termination criteria, it is first important to place the updates in wider historical context. From this view, an RRE’s ability to terminate ORM regarding older claims it considers administratively closed or otherwise inactive, due to the claimant no longer actively treating, has long been a problem area. A major reason for this is CMS’s general rule that an ORM termination report should not be filed in situations if “the ORM is subject to reopening or otherwise subject to an additional request for payment”[11] which, by its broad nature, has the effect of keeping ORM open.

As exceptions to this rule, CMS has, for quite some time, allowed RREs to terminate ORM if it can, as outlined above, obtain “a statement (hard copy or electronic) signed by the beneficiary’s treating physician that no additional medical items and/or services associated with the claimed injuries will be required,” or, alternatively, “if ORM has terminated under state law, or per the terms of the insurance contract (such as the exhaustion of maximum coverage benefits).”[12] CMS has not made any changes to these existing policies.

Now, as part of the new User Guide updates, CMS is adding additional situations which would permit an RRE to file an ORM termination report, as noted above in bold. Overall, RREs will likely welcome, at least to some degree, this additional opportunity to terminate ORM. However, from a practical standpoint, the additional guidelines contain several qualifiers and exclusions, and each noted criteria point must be met, which could diminish their effectiveness. As part of this, RREs may also find the $25,000 medical payment limit and 5-year limitation rule too restrictive. Going forward, it will be interesting to see if these new guidelines help RREs terminate ORM in older claims they view as administratively closed or otherwise inactive. This will likely be a mixed bag depending on claim type and case facts.

Event Table Updates

CMS notes that it is making the following updates to the Event Table:

The Event Table, which helps RREs and their agents determine when, and how, to send records on the Claim Input File, has been updated to cover situations where ongoing responsibility for medicals (ORM) ends for one injury due to Total Payment Obligation to Claimant (TPOC), but then continues for another injury (Chapter IV, Section 6.6.4).[13]

Comments

Regarding this update, it is noted that CMS had previously provided clarification regarding partially resolved ORM claim scenarios during their April 1^st, 2021 NGHP Town Hall. As referenced in the Town Hall, CMS has added these user guide updates which encompass the clarifications provided during that Town Hall session.

Electronic File Transfer (EFT)

CMS also indicates that the EFT file-naming conventions for inbound and outbound files have been updated (Chapter IV, Section 10.2).[14]

Comments

The EFT changes, noted in the new User Guide, and as initially referenced in NGHP User Guide Version 6.2 (January 11, 2021), should have minimal impact as these changes apply only to those RREs utilizing CMS’ Connect:Direct file transfer protocol. This particular file transfer protocol is utilized by a very limited cross-section of NGHP RREs. However, for those RREs utilizing Connect:Direct for their Section 111 data transfers it will be important to make note of the current dataset names and to utilize them accordingly moving forward.

SP55 Error Code

CMS advises that the SP55 error code (MSP Effective Date is invalid or less than the earliest beneficiary Part A or Part B Entitlement Date) has been added (see Chapter V, Appendix F, Table F-4: Claim Response File Error Code Resolution Table).[15]

Comments

Regarding this newly published code, the reader may note a similarity to CMS’ prior SP31 error code which was officially retired as of April 5^th, 2021, as announced by CMS in its Section 111 NGHP User Guide (Version 6.1, November 10, 2020).

Specifically, as part of NGHP User Guide (Version 6.1), CMS stated that starting April 5, 2021 “Claim Input File Detail Records, and Direct Data Entry (DDE) records, submitted prior to the effective date of the injured party’s entitlement to Medicare will be rejected and returned with a Disposition Code ‘03’ instead of an SP31 error.”

Of note, the change related to the former SP31 error code as noted above remains in effect today. As for the SP55 error code, in general this should not replace the ‘03’ disposition in these scenarios despite the very similar situations to which it may apply. In this regard, the ‘03’ disposition should continue to be returned by CMS in the vast majority of the aforementioned outlined scenarios. However, on rare occasions, an RRE may potentially receive this SP55 error as opposed to the ‘03’ disposition. In this event, this should be interpreted similarly, and the guidance CMS has provided RREs is, for all intents and purposes, the same. Should an SP55 error be received on a claim within an RRE’s Claim Response File, CMS has indicated that no correction is necessary on the part of the RRE and that the record should simply be resubmitted on the RRE’s next file submission.

MMSEA X12 270-271 Companion Guide updates

In addition to releasing the new User Guide, CMS has also published Version 5.5 of their 270/271 Health Care Eligibility Benefit Inquiry and Response Companion Guide for NGHP Entities. This supplemental guide is intended for use by RREs who choose to utilize their own ANSI X12 translator software, as opposed to CMS’s free HEW translator software, in conjunction with the National Electronic Data Interchange Transaction Set Implementation Guide and Health Care Eligibility Benefit Inquiry and Response, ASC X12N 270/271 Implementation Guide. The newly published Version 5.5 contains updates in relation to the mapping of the aforementioned data elements being added to the NGHP Query Response Files as part of CMS’s implementation of the PAID Act

Questions?

Of course, please do not hesitate to contact the authors if you have any questions. Finally, please note that ISO Claims Partners will be incorporating any applicable technical reporting changes necessitated by CMS’s updates into its various reporting platforms.

[1] It is noted that the information contained in this Alert is also incorporated in the new User Guide.

[2] CMS’s Section 111 NGHP User Guide, Chapter IV (Version 6.4, June 11, 2021), Chapter 1, p. 1-1.

[3] In pertinent part, the text of the PAID Act reads as follows:

(ii) SPECIFIED INFORMATION.— In responding to any query made on or after the date that is 1 year after the date of the enactment of this clause from an applicable plan related to a determination described in subparagraph (A)(i), the Secretary, notwithstanding any other provision of law, shall provide to such applicable plan—

(I) whether a claimant subject to the query is, or during the preceding 3-year period has been, entitled to benefits under the program under this title on any basis; and

(II) to the extent applicable, the plan name and address of any Medicare Advantage plan under part C and any prescription drug plan under part D in which the claimant is enrolled or has been enrolled during such period.”

H.R. 8900, Further Continuing Appropriations Act, 2021, and Other Extensions Act, Title III, Offsets, Sec. 1301, (ii), Transparency of Medicare Secondary Payer Reporting Information.

[4] CMS’s Section 111 NGHP User Guide, Chapter II (Version 6.4, June 11, 2021), Chapter 1, p. 1-1.

[5] CMS’s Section 111 NGHP User Guide, Chapter IV (Version 6.4, June 11, 2021), Chapter 1, p. 1-1.

[6] Id.

[7] CMS’s Section 111 NGHP User Guide, Chapter V (Version 6.4, June 11, 2021), Chapter V, Appendix K, p. K-1.

[8] CMS’s Section 111 NGHP User Guide, Chapter IV (Version 6.4, June 11, 2021), Chapter 1, p. 1-1.

[9] See, CMS’s Section 111 NGHP User Guide, Chapter V (Version 6.4, June 11, 2021), Chapter V, Appendix E, pages E-6 to E-30.

[10] CMS’s Section 111 NGHP User Guide, Chapter III (Version 6.4, June 11, 2021), Chapter, Section 6.3.2.

[11] CMS’s Section 111 NGHP User Guide, Chapter III (Version 6.4, June 11, 2021), Chapter, Section 6.3.2.

[12] Id.

[13] CMS’s Section 111 NGHP User Guide, Chapter V (Version 6.4, June 11, 2021), Chapter 1, p. 1-1.

[14] Id.

[15] Id.