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CMS releases new NGHP Section 111 User Guide (Version 6.2, January 11, 2021)

By Mark Popolizio, Jeremy Farquhar  |  January 22, 2021

The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 NGHP User Guide (Version 6.2, January 11, 2021) regarding non-group health plans (liability, no-fault, and workers’ compensation). This updated guide replaces Version 6.1 (November 10, 2020).  

As usual, CMS lists its updates at the beginning of each User Guide chapter on a “Summary” page. Reviewing these pages indicates that CMS has made updates to Chapter II (Registration Procedures), Chapter III (Policy Guidance), Chapter IV (Technical Guidance), and Chapter V (Appendices). Overall, CMS made various changes to its Section 111 reporting directives, most notably making Policy Number (Field 54) a key field and expanding ORM termination dates up to 75 years. Also, CMS issued a retraction regarding one item addressed in its prior Version 6.1 update.

The following provides a general overview of the updates made by CMS in User Guide (Version 6.2):

Policy Number (Field 54) is now a key field

CMS has made updates to the Policy Number field (Field 54). Specifically, CMS states that Policy Number (Field 54) has been added as a key field. If this field changes, RREs must submit a delete Claim Input File record that matches the previously accepted add record, followed by a new add record with the changed information (i.e., delete/add process).[1]

Additional CMS references include: Chapter IV (Technical Guidance), Sections 6.1.2, 6.6.1, 6.6.2, and 6.6.4.

Future ORM Termination Dates (Field 79) – now accepting ORM termination dates up to 75 years for certain claims

CMS has made updates to address situations where RREs can identify future ORM termination dates based on the insurance contract terms. In these situations, CMS states that RREs can now enter a future ORM Termination Date (Field 79) up to 75 years from the current date.

On this point, in Chapter IV (Technical Guidance), Section 6.7.1, CMS states, in part, that: “RREs are not to submit an expected, anticipated, or contingent ORM Termination Date. ORM Termination Dates should only be submitted when the termination of ORM is certain. Future-dated ORM Termination Dates can be dated no more than 75 years from the current date.“[2] 

Of note, before this update, CMS would only allow RREs to post future ORM termination dates up to 6 months into the future. This change is something many NGHP RREs have encouraged CMS to consider for quite some time, and it will likely be well received.   

Additional CMS references include: Chapter IV (Technical Guidance), Section 6.7.1, Chapter V (Appendices), Appendix A and Appendix F.

CMS issues a “retraction” – CP03 will not become a soft edit

In its prior Version 6.1 Update, CMS announced several input errors would become “soft” errors starting April 5, 2021. However, as part of the new User Guide (Version 6.2), CMS has advised that CP03 will not become a soft edit. As part of this update, CMS notes that the Office Code/Site ID (Field 53), which triggers CP03, is used to identify correspondence addresses, and if incorrect, could result in the mail sent to the wrong place. Therefore, CMS advises that this error will continue to reject the record.[3]

Additional CMS references include: Chapter V (Appendices), Appendix F.

CMS’s $750 low dollar threshold (2021)

Through an alert dated November 25, 2020, CMS advised that it was maintaining its $750 low dollar reporting threshold for certain claims in 2021. CMS is now incorporating this prior update into the new User Guide. 

In its change “Summary” page at the beginning of Chapter III, CMS describes its low dollar threshold as follows: “As of January 1, 2021, the threshold for physical trauma-based liability insurance settlements will remain at $750. CMS will maintain the $750 threshold for no-fault insurance and workers’ compensation settlements, where the no-fault insurer or workers’ compensation entity does not otherwise have ongoing responsibility for medicals.”

This verbiage is the exact language also used by CMS in its November 25, 2020 alert. In reviewing this language, it can be interpreted to mean that applicability of the low-dollar threshold for liability claims is limited to “physical trauma-based” liability settlements, while there is no such limitation referenced concerning no-fault and workers’ compensation settlements.

However, of note, in reviewing the actual sections within Chapter III of the User Guide that address the low dollar threshold, the verbiage in these sections related to workers' compensation and no-fault claims seems to be inconsistent with the language used by CMS in its November 25, 2020, alert and the general Summary page to Chapter III. Specifically, the language used in section 6.4.2 (no-fault insurance TPOCs) reflect that the low dollar threshold may also be limited to physical trauma-based claims regarding no-fault claims, and potentially workers’ compensation claims under section 6.4.4 (workers’ compensation TPOCs).  

For example, in section 6.4.2 (no-fault insurance TPOCs), CMS indicates, in part, that the $750 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.” Regarding workers’ compensation, in section 6.4.4 (workers’ compensation TPOCs), CMS states, in part, that “[t]his 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.” Based on the title of this section, it appears CMS may intend this limitation to also apply to workers’ compensation claims, although the section uses the word “liability” (instead of “workers’ compensation”), as noted above. In the larger context, these areas may need further clarification and consistency from CMS, from both a policy and verbiage standpoint. 

Until CMS issues further clarification on this point, it may be a prudent practice for RREs to assume that CMS intends its low dollar threshold to apply to physical trauma-based cases for all claims (not just liability).

Additional CMS references include: Chapter III (Policy Guidance), Sections 6.4.2, 6.4.3, and 6.4.4, and Chapter IV (Technical Guidance), Sections 6.4.2, 6.4.3, and 6.4.4.

Enterprise File Transfer (EFT) protocol updates

CMS notes that it is making changes to move certain electronic file transfer data exchanges to the CMS Enterprise File Transfer (EFT) protocol as part of its efforts to modernize the Coordination of Benefits & Recovery (COB&R) operating environment. As part of this change, CMS notes the data exchange with the COB&R program via Connect:Direct to GHINY SNODE will be discontinued and that the final cutover is targeted to occur in April 2021. File naming conventions and other references have been updated in this guide. CMS instructs RREs to contact their EDI Representative for details.[4] Overall, it is noted that this EFT update will likely have minimal impact on NGHP RREs as this is not a commonly used file transfer protocol. 

Additional CMS references includes: Chapter II (Registration Procedures), Section 4.2.4, and Chapter IV (Technical Guidance), Sections 10.2 and 10.3

Questions?

Please note ISO Claims Partners will be incorporating any applicable technical reporting changes necessitated by CMS’s updates into its various reporting platforms. In the interim, please contact the authors if you have any questions regarding CMS’s latest changes and updates made in the User Guide (Version 6.2).


[1] See Section 111 NGHP User Guide (Version 6.2, January 11, 2021), Chapter IV (Technical Guidance), Chapter 1: Summary of Version 6.2 Updates.

[2] See Section 111 NGHP User Guide (Version 6.2, January 11, 2021), Chapter IV (Technical Guidance), Chapter 1 : Summary of Version 6.2 Updates.

[3] See Section 111 NGHP User Guide (Version 6.2, January 11, 2021), Chapter V (Appendices), Chapter 1: Summary of Version 6.2 Updates.

[4] See Section 111 NGHP User Guide (Version 6.2, January 11, 2021), Chapter II (Registration Procedures), Chapter 1: Summary of Version 6.2 Updates; and Chapter IV (Technical Information), Chapter 1: Summary of Version 6.2 Updates.


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.

Jeremy Farquhar is a senior product consultant at ISO Claims Partners, a Verisk business. You can contact Jeremy at Jeremy.Farquhar@verisk.com.