Section 111 NGHP User Guide (V7.6): updates "cumulative injury" definition & TIN errors

July 9, 2024 / 3 min read

The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 NGHP User Guide (Version 7.6, July 1, 2024) 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. Reviewing these pages indicates that updates were made to Chapter I (Introduction and Overview) Chapter III (Policy Guidance), Chapter IV (Technical Information), and Chapter V (Appendices). In general, as outlined below, CMS has added an expanded definition of “cumulative injury” and provides information on how to resolve TIN errors.

physicians desk

The following provides an overview of the changes made in NGHP User Guide (Version 7.6):

Cumulative Injury

CMS notes that “[a]n expanded and specific definition has been [added] to clarify the qualification of a cumulative injury for Section 111 NGHP reporting.”^[1] This additional definition appears to clarify and distinguish cumulative trauma injuries from injuries involving ingestion, exposure, and implantation reporting for the purposes of Section 111 reporting.

In this regard, CMS has added the following definition of “cumulative injury” in the User Guide:

“Cumulative injury refers to those categories of injuries that may persist or grow in severity, intensity, or pain but for which a formal diagnosis may not occur until a later date. Examples of cumulative injuries include, but are not limited to, carpal tunnel syndrome, or back pain that is not the result of an acute trauma. Exposure, ingestion, and inhalation injuries are not considered cumulative injuries for purposes of calculating DOI or any other reporting requirements.” Section 111 NGHP User Guide (Version 7.6, July 1, 2024), Chapter I, (Chapter 2) and Chapter III, (Chapter 2).

CMS also includes this verbiage following the above definition in Chapter I, (Chapter 2):

“This CMS definition differs from the definition of that generally used by the insurance industry under specific circumstances. For the DOI used by the insurance and workers’ compensation industry, see Field 13 of the Claim Input File Detail Record in the NGHP User Guide Appendices, Chapter V.” Section 111 NGHP User Guide (Version 7.6, July 1, 2024), Chapter I, (Chapter 2).

In addition, CMS also references that related updates regarding this matter were made to Chapter V, Section 3.2 (data format standards). This section can be viewed here.

TIN errors

Overall, as part of this update, CMS has emphasized the importance of correcting address errors in the TIN reference file immediately and notes that updates were made to Chapter IV stating as follows: “Information on how to resolve TIN address errors was added (Sections 6.3.3 and 6.6.5).”^[2] Specifically, CMS added instructions to contact the local post office when a correct address fails validation with the United States Postal Service. Section 6.3.3 can be viewed here. Section 6.6.5 can be viewed here.

Questions?

Please do not hesitate to contact the authors if you have any questions, or to learn how Verisk can help you address Section 111 reporting issues.

[1] Section 111 NGHP User Guide (Version 7.6, July 1, 2024), Chapter

[2] Section 111 NGHP User Guide (Version 7.6, July 1, 2024), Chapter IV (Chapter 1).