On December 6th, the Centers for Medicare and Medicaid Services (CMS) held a non-group health plan (NGHP) Section 111 webinar during which the agency discussed a wide variety of Section 111 reporting topics as outlined below. Overall, the bulk of the presentation consisted of refresher information on several Section 111 reporting aspects, although CMS did note an upcoming change to the CP13 soft edit code (no-fault insurance limit threshold). Of note, CMS did not discuss nor provide any information on the status of the agency’s Section 111 civil money penalties (CMPs) “final rules” which are currently pending review by the Office of Information and Regulatory Affairs (OIRA).
Appearing as primary presenters for CMS were Rick Mazur and Angel Pagan. After brief introductory comments, CMS addressed numerous Section 111 related topics and then took attendee questions for the remainder of the session as summarized in general as follows:
Importance of the Accuracy of Section 111 Reporting
CMS began the main portion of their presentation by stressing the importance of accurate Section 111 reporting. In doing so they were careful to highlight the link between the accuracy of the reported Section 111 data and the subsequent accuracy of their conditional payment recovery process. On this point, although not specifically mentioned by CMS, the author reminds the reader that one of CMS’s outstanding Section 111 CMP proposals seeks to penalize RREs in situations where the RRE’s response to CMS recovery efforts contradicts the RRE’s Section 111 reporting.
Total Payment Obligation to the Claimant (TPOC) Reporting
CMS then moved on to provide an overview of general requirements related to the Section 111 TPOC reporting trigger, paying special attention to the types of expenses or payments which they might expect to be included within a reported “TPOC Amount.” In covering this topic, they essentially listed the same examples of expenses which were included within their NGHP Section 111 User Guide found within Chapter III, Section 6.4 which states: “The computation of the TPOC amount includes, but is not limited to, all Medicare covered and non-covered medical expenses related to the claim(s), indemnity (lost wages, property damages, etc.), attorney fees, set-aside amount (if applicable), payout totals for all annuities rather than cost or present values, settlement advances, lien payments (including repayment of Medicare conditional payments), and amounts forgiven by the carrier/insurer.”
While most expenses specifically outlined above are relatively straight forward, one item included within Section 6.4 which, in the author’s experience, has raised questions is CMS’s reference to “amounts forgiven by the carrier/insurer.” While the other listed items tend to be items which would be ultimately represented by funds being paid out to the claimant as a part of an overarching settlement, “amounts forgiven by the carrier/insurer” are, conversely, not something which are included as part of the typical settlement amount. As such, the inclusion of this item (where applicable) as part of the TPOC calculation has raised, in author’s experience, questions from RREs and additional clarity from CMS regarding this requirement would have likely been welcomed by many RREs. Unfortunately, this was not specifically addressed by CMS during this session.
Indemnity Only Settlements
Next up was discussion of indemnity settlements reporting. CMS made a point to clarify that indemnity only settlements, where medicals remain open and additional related settlement may still be pending, are not reportable via Section 111. However, CMS was careful to point out that, if indemnity payments are included in a larger overarching settlement where medical payments are also included, or the settlement language would have the effect of releasing medicals, that those indemnity payments should be included as a part of the reported TPOC Amount.
NGHP User Guide Event Tables
CMS strongly encouraged attendees to refer to the Event Tables included within Section 6.6.4 of Chapter IV of their NGHP User Guide which provide a variety of reporting scenarios and include specific examples of how those scenarios should be handled via the Section 111 reporting process. During this portion of the presentation, CMS highlighted two specific Event Table scenarios which both relate to situations involving partial claim resolution. First, where ORM ends for one or more injury, yet remains open for others, their guidance, as stated in Chapter IV, Section 6.6.4 of the NGHP User Guide, suggests that an update be submitted to remove any ICD codes for which ORM has ended while ICD codes for which ORM remains open should be retained within the updated coverage. Second, in scenarios where ORM ends for one or more injuries, due to TPOC, their guidance in Section 6.6.4 suggests both an update similar to the aforementioned, in combination with an add record to separately report the TPOC. This separate add transaction would include the appropriate TPOC info where ORM is submitted as ‘N’ (No) and only the resolved ICD codes, removed via the update to the original report, would be included.
Reporting Deceased Beneficiaries
Another topic addressed was reporting required in relation to deceased beneficiaries. CMS reminded attendees that a Section 111 report is required in relation to a deceased beneficiary in the event that a TPOC event occurs subsequent to their passing. They also made note that additional claimant information may be reported in these scenarios although it is not required.
CMS’s Most Common Error Codes by Volume
As part of this session, CMS also provided a breakdown of the most commonly triggered errors based on recent agency statistics, which are summarized as follows with the below listed in order of highest to lowest volume as noted by CMS:
- CR12 – Representative Phone: Often triggered by inclusion of other representative info where the phone was not included. (“Soft Edit” which will not cause a rejection).
- SP49 – No record found for delete: Often returned in situations where a coverage may have already been deleted prior to the Section 111 submission, sometimes as a result of a beneficiary call to the BCRC.
- CI05 – ICD Diagnosis Code 1: Most often triggered due to a missing required ICD code value.
- TN99 – Invalid TIN/Office Code: No matching valid TIN Detail Record found for TIN/Office Code values provided.
- CJ04 – TPOC Amount 1: Often triggered when a TPOC Date is reported without a corresponding TPOC Amount.
- CI03 – Alleged Cause of Injury: Triggered when an invalid ICD code is submitted within the Alleged Cause of Injury field. This is no longer a required data element and this error could be avoided by simply refraining from reporting it altogether. (“Soft Edit” which will not cause a rejection)
- CP13 – No-Fault Limit < $1,000: Triggered when the value reported as the No-Fault Insurance Limit is less than $1,000. If the value being reported is verified as accurate, no action is necessary upon receipt. (“Soft Edit” which will not cause a rejection)
- TN01 – Invalid RRE TIN: Triggered when a TIN Detail Record within the TIN Reference File is rejected. Often times this may be due to an address validation failure.
- CJ01 – ORM Indicator: Returned in scenarios where a valid ORM Indicator value of ‘Y’ or ‘N’ is not provided
Additional Error Code Related Guidance
After detailing the most commonly occurring error codes, CMS then provided a bit of additional guidance/clarification regarding error codes in general. Here it was noted that standard error codes result in rejection of the submitted coverage and those errors must be corrected and coverage must be resubmitted via the RRE’s next quarterly submission. In contrast to standard error codes which result in rejection of submitted coverage, CMS also discussed a subset of error codes which, as of April 2021, CMS now considers “soft edits.” These are errors that do not result in a rejection, and coverage records may still be accepted, but subsequent review, correction and resubmission is still expected.
Upcoming change to the CP13 soft edit code (no-fault insurance limit threshold)
In addition to the general feedback regarding “soft edits,” CMS also noted an upcoming change to their ‘CP13’ soft edit code. Specifically, as of January 2023, CMS stated on the webinar that the agency will be lowering the No-Fault Insurance Limit threshold which they utilize to trigger this error. This error is presently being returned in scenarios where the submitted No-Fault Insurance Limit is less than $1,000. As of January 2023, that dollar value will drop to $500. This is based on CMS’s recognition that valid sub-$1,000 dollar policy limits are not as uncommon as they may have previously anticipated.
ICD Diagnosis Code Reporting
CMS then focused on proper ICD code reporting. In doing so, they highlighted a number of important facts including that partial ICD codes are not accepted; RREs should only report ICD codes relevant to the injuries directly connected to the incident being reported; all reported codes must match a code included within the valid ICD-9 or ICD-10 code listings published in relation to the Section 111 process; and reports for dates of incident 10/1/15 or later must utilize ICD-10, as opposed to ICD-9, codes. In addition, CMS provided additional feedback regarding proper ICD code formatting and information about where current accepted and excluded code listings may be accessed.
Review of Key Fields
From here CMS moved into an overview of the data elements defined as key fields for the Section 111 reporting process. Those four key fields include the Plan Insurance Type, CMS Date of Incident, ORM Indicator and Policy Number. Appropriate protocol for correcting previously submitted key field values was discussed and it was noted that a “Delete-Add” would be required where a delete transaction is submitted to remove the prior report coupled with an add transaction which includes a re-report of the same coverage with the corrected key field values.
Additional information was provided in relation to the access afforded to an entity reported as an RRE’s Recovery Agent. CMS provided refresher outlining how Recovery Agents are designated via inclusion within an RRE’s TIN Reference File and that this authorizes the Recovery Agent to resolve issues related to Conditional Payment Notices (CPNs) and Conditional Payment Letters (CPLs). CMS also provided important clarification indicating that the automatic authorization afforded to Recovery Agents ends at the point that a demand is issued and that an additional written authorization is required in order for a Recovery Agent to assist in any further resolution subsequent to CMS’s issuance of a demand.
Changes re: Section 111 reporting agent/entity
As their final topic within their prepared presentation, CMS addressed scenarios in which there is a change in the Section 111 reporting entity or agent during the lifespan of a claim. On this point, CMS discussed two specific scenarios as follows:
- An RRE moves new business to a new TPA while previously reported pre-existing claims continue to be handled by the prior TPA
In this scenario, CMS suggested that the RRE would need to register for a new RRE ID which would be utilized by their new TPA to perform any new reporting moving forward. The original RRE ID should continue to be utilized by the prior TPA in order to continue any additional reporting required in relation the claims that they would continue to handle moving forward. In this scenario, no updates to pre-existing claims are required solely based on the transition to a new TPA.
- An RRE moves both new business and pre-existing claims to a new TPA (commonly referred to as a “TPA takeover” scenario)
Here CMS suggests that the RRE may utilize the same pre-existing RRE ID, formerly used to report in connection with the prior TPA, while transitioning all reporting under the pre-existing ID over to the new TPA. CMS instructs that coverages reported by the prior TPA should be deleted. A delete would need to be submitted using all of the same key fields (CMS DOI, Plan Insurance Type, original Policy Number and ORM Indicator) while the new add record should include the new Policy Number assuming that the Policy Number would change as a result of the transition.
While the first scenario is straight forward, a bit of additional clarification may have been helpful in relation to the second scenario. For example, one might assume that the expectation would be that the original TPA would be the entity expected to submit the delete coverage for the original report while the new add record would then be submitted by the new TPA but that wasn’t 100% clear based on the information CMS discussed on the webinar. In the author’s experience, the problem that may often occur in these scenarios is that the new TPA may not have, and may have trouble obtaining, the policy number utilized for the initial report made by the original TPA. If that happens to be the case, the original TPA might need to perform the delete while the new TPA may need to perform the new add. However, if that is the expectation, timing of the reports may also be a bit of an issue. In this regard, from the author’s view, expectations regarding logistics and timing of the reports in these “TPA takeover” scenarios are still somewhat unclear.
CMS then fielded questions from attendees via submissions through the chat functionality. While full recap of all the questions addressed by CMS is beyond the scope of this overview, there were a number of questions which elicited some notable feedback from CMS which are outlined in general:
- Section 111 data sharing with Medicare Advantage and Part D Plans - CMS indicated that MAP and Part D Plans are provided with coverage information in relation to ORM coverages and workers’ comp set aside records. TPOC information is not yet being shared with MAP and Part D Plans but potential sharing of TPOC information is presently being discussed.
- ICD-10 to ICD-11 transition - In response to this question, CMS indicated that there is not yet a planned timeframe for a transition to ICD-11 but that RREs will be notified well in advance of any future plans.
- Highlighting/identifying new changes to CMS’s updating of ICD code listings each October - Regarding this suggestion, CMS indicated that this might be feasible and they would take this into consideration for future updates.
- Question regarding whether CMS reviews the data submitted via the monthly eligibility query process in order to identify scenarios in which they might expect to receive a subsequent coverage report on an RRE’s claim input file submissions - In response, CMS confirmed that they do not presently utilize the query file process to attempt to identify scenarios in which a coverage report might be required or expected. They did not indicate that they have any intention of attempting to do so moving forward.
- CMS’s “low dollar” threshold - An attendee asked whether the TPOC thresholds will remain at $750 moving forward. CMS indicated that they expect to publish an alert within the next couple weeks which will provide appropriate information regarding TPOC thresholds for 2023.
Of course, please do not hesitate to contact the author if you have any questions. In the interim, keep in mind that Verisk can help you meet your Section 111 reporting obligations through our innovative and user-friendly MSP Navigator reporting tool. Also, we offer a popular Section 111 audit/review service which can help gauge the status of your current program and how you may be able to improve your reporting practices.