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CMS releases new NGHP Section 111 User Guide (Version 5.9)

By Mark Popolizio, Mike Gibbon  |  July 1, 2020

The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 NGHP User Guide (Version 5.9, June 29, 2020) regarding non-group health plans (liability, no-fault and workers’ compensation). This updated guide replaces Version 5.8 (January 31, 2020). 

As usual, CMS lists its updates at the beginning of each user guide chapter in a “Summary” page. Reviewing these pages indicates CMS has made updates to Chapter III (Policy Guidance), Chapter IV (Technical Guidance), and Chapter V (Appendices).

In general, CMS’s changes can be summarized as follows:

Reminder regarding CMS’s $750 TPOC/settlement reporting threshold

CMS reminds RREs that the $750 threshold does not apply to non-trauma/exposure liability cases.

The exact wording noted in Chapter III, and Chapter IV “Summary” pages are as follows:

  • A reminder has been added that while the threshold for physical trauma-based liability insurance settlements remains at $750, this threshold does not apply to non-trauma liability reporting for alleged ingestion, implantation, or exposure cases. Any settlement, regardless of amount, should be reported for these types of cases. (Section 6.4.2, 6.4.3 and 6.4.4).

Updates to the guide regarding CMS’s recent no-fault/med-pay “reminder” alert

CMS updated the user guide regarding its recent No-Fault/Med-Pay alert. The user guide reminded RREs the dollar limit to report for No-Fault Insurance Limit field should represent a combined total of Med-Pay and Personal Injury Protection (PIP) coverage amounts. See our recent article on this alert update.   

CMS’s exact update on this item, as noted in Chapter IV’s “Summary” reads as follows:

  • The limit dollar amount that triggers a threshold error has been adjusted from $99,999,999 to $99,999,999.99. This error occurs any time the No-Fault Insurance Limit amount or the cumulative value of all reported TPOCs (detailed and auxiliary records) exceed this limit. Additionally, the No-Fault Insurance Limit field number has been corrected under “Exceptions.” (Section 7.3.2).
  • When considering the requirements for the Ongoing Responsibility for Medicals (ORM), remember, per current policy, that the dollar limit for No-Fault Insurance Limits (Field 61) represents a combined total of Med-Pay and Personal Injury Protection (PIP) (Section 7.1).

Further updates are noted in Chapter V’s “Summary” page as follows:

  • When considering the requirements for the Ongoing Responsibility for Medicals (ORM), remember, per current policy, that the dollar limit for No-Fault Insurance Limits (Field 61) represents a combined total of Med-Pay and Personal Injury Protection (PIP) (Appendix A).

Clean-up of clerical errors in Appendices I (Excluded ICD Codes) and F (Disposition Codes)

In Chapter V, CMS made some clerical updates as follows:

  • Several no-fault excluded ICD-10 codes have been removed from the Excluded ICD-10 and ICD-9 Diagnosis Codes table (Appendix I).
  • The CR02 claim response file error code field number has been corrected (Appendix F) (Table F-4).

Please contact Mike Gibbon at mgibbon@verisk.com or Jeremy Farquhar at jeremy.farquhar@verisk.com if you have any questions.


Mark Popolizio, J.D., is vice president of MSP compliance and policy at ISO Claims Partners, a Verisk business. You can contact Mark at mpopolizio@verisk.com.

Mike Gibbon is the assistant director of product operations at ISO Claims Partners, a Verisk business. You can contact Mike at mgibbon@verisk.com.