The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 NGHP User Guide (Version 6.3, April 5, 2021) regarding non-group health plans (liability, no-fault and workers’ compensation). This updated guide replaces Version 6.2 (January 11, 2021).
As usual, CMS lists its updates in the beginning of each User Guide chapter in a “Summary” page. Reviewing these pages indicates that CMS has made updates to Chapter III (Policy Guidance); Chapter IV (Technical Guidance); and Chapter V (Appendices).
In general, the majority of information contained in the “Summary” update pages to Chapters III, IV, and V either simply outlines policy guidance that CMS has previously released through prior NGHP User Guide updates and Alerts or makes minor clarifications to that prior information. One exception to this, as discussed more fully below, involves new changes CMS has made regarding the “CP11” error code logic related to the reporting of zero-dollar amount values submitted for the no-fault insurance limit (field 61).
Of note, CMS’s new NGHP User Guide does not contain any information regarding PAID Act implementation or the guidance it provided on the recent NGHP Townhall call regarding partially resolved ORM scenarios. It is anticipated that these topics will be covered in a future user guide update.
A general overview of the updates made by CMS in User Guide (Version 6.3, April 5, 2021) is provided as follows:
In the Summary page to Chapter III, CMS outlines the following information:
To align with the terms and conditions regarding the acceptance of Ongoing Responsibility for Medicals (ORM) as described in Section 6.4, the language around periodic payments or one-time settlements to compensate for lost wages has been clarified (Section 6.5.1).
The above language essentially adds a point of clarification regarding existing guidance related to the reporting of periodic payments in workers’ compensation and no-fault cases as more fully described in Chapter III, section 6.5.1.
Based on the updates made in Chapter III, section 6.5.1, the guidance regarding the reporting of periodic payments now reads as follows with the new verbiage added by CMS reflected in bold font for the reader’s easier identification:
[i]n situations where the applicable workers’ compensation or no-fault law or plan requires the RRE to make regularly scheduled periodic payments, pursuant to statute, for an obligation(s) other than medical expenses, or a one-time ‘indemnity-only’ payment or settlement for obligation(s) other than medical expenses is made to or on behalf of the claimant, the RRE does not report these periodic payments or one-time settlements as long as the RRE separately assumes/continues to assume Ongoing Responsibility for Medicals (ORM) and reports this ORM appropriately. Otherwise, such scheduled periodic payments or settlements are considered to be part of and are reported as ORM. The periodic payments or one-time settlement to compensate for lost wages are not reported as TPOCs but may be included to compute the total TPOC amount. (Note: TPOC computation is outlined in Section 6.4.).
In assessing this update, it would seem important to review the added language in conjunction with the specifics of TPOC computation as outlined in Section 6.4 to avoid potential confusion. On this point, it is worth specifically noting that CMS states, as part of its TPOC computation definition, that only payments made “in addition to or apart from ORM” should be included in the calculation of a TPOC amount.
Certain claim input errors will no longer result in the input record being rejected
In the Summary page to Chapter IV, CMS outlines the following information:
- Several Section 111 input record errors that would cause a record to reject will no longer cause the input records to be rejected. RREs, however, will continue to receive the errors on their response files, and they should correct and resubmit on their next quarterly file The errors include: CC05, CC11, CC12, CC13, CC25, CC31, CC32, CC33, CC45, CC51, CC52, CC53, CC65, CC71, CC72, CC73, CI02, CI03, CI25, CP06, CP07, CP08, CP09, CP10, CP13 (new), CR11, CR12, CR13, CR14, CR31, CR32, CR33, CR 34, CR51, CR52, CR53, CR54, CR71, CR72, CR73, CR 74, CR91, CR92, CR93, CR94, and TN30 (Section 7.1 and NGHP Chapter V).
- 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 (Section2).
It is noted that CMS had previously outlined this guidance in NGHP User Guide (Version 6.1, November 10, 2020) and NGHP User Guide (Version 6.2, January 11, 2021). In relation to this directive, the noted claim input errors will no longer cause the input record to be rejected. However, as noted, RREs will continue to receive the errors on their response files, and they should correct and resubmit on their next quarterly file submission. Per CMS’s prior announcements, this policy update became effective as of April 5, 2021.
With that said, in looking at the first bullet point, there are two minor changes of note. The first is the removal of the ‘CP03’ error which was initially identified as a part of this group of error codes which will no longer cause a record to reject. This code was initially included within both CMS’ November 12, 2020 Alert and NGHP User Guide (Version 6.1). CMS then retracted CP03 as one of the included codes in NGHP User Guide (Version 6.2, January 11, 2021). The other minor change is simply the removal of the term “soft errors” which CMS had previously been using to describe this group of codes. No reason was given as to why CMS is no longer using the phrase “soft errors,” although this would appear to be purely semantic in that it does not change CMS’s noted policy on this issue. Regarding the second bullet point, this simply reiterates guidance that had already been published via NGHP User Guides versions 6.1 and 6.2.
Appendices updates -- claim input errors
In the Summary page to Chapter V, CMS outlines, in part, the highlighted information:
- Several Section 111 input record errors that would cause a record to reject will no longer cause the input records to be rejected. RREs, however, will continue to receive the errors on their response files, and they should correct and resubmit on their next quarterly file submission. The errors include: CC05, CC11, CC12, CC13, CC25, CC31, CC32, CC33, CC45, CC51, CC52, CC53, CC65, CC71, CC72, CC73, CI02, CI03, CI25, CP06, CP07, CP08, CP09, CP10, CP13 (new), CR11, CR12, CR13, CR14, CR31, CR32, CR33, CR 34, CR51, CR52, CR53, CR54, CR71, CR72, CR73, CR 74, CR91, CR92, CR93, CR94, and TN30 (Appendix F)
- A new edit has been added and applied to NGHP Claim Input File Detail Record files when users submit a no-fault insurance claim where the policy limit is less than $1000.00. The input files will be accepted but a new CP13 error will be returned on the response files to notify users to confirm the dollar amount submitted. Direct Data Entry (DDE) submitters will see a message on the Insurance Information page but will be able to proceed with data entry without correcting (Appendix F)
- 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.
Most of the information included in the summary for the Chapter V updates had also been previously published. The first three bulleted items provide no new substantive changes which had not already been published via prior versions of the guide.
Breaking down the above bulleted items, please refer to the discussion contained above in relation to the Chapter IV updates regarding the first bulleted item. Regarding the second bullet, there does not appear to be any change from what had already been published in regard to the new “CP13” error in NGHP User Guide versions 6.1 and 6.2, with the exception of the removal of the term “soft error” as discussed above which, again, appears to be purely semantic in nature. Similarly, the item addressed in the third bullet point, which is the same as the second bulleted item in the Chapter IV summary above, also appears to be a reiteration of the guidance already published in prior two versions of the guide.
CP11 error regarding no-fault insurance limit (field 61) - NEW
In addition to the above noted updates to Chapter V (Appendices), CMS has announced a new policy update in Chapter V regarding CP11 errors and the no-fault insurance limit field (61).
On this point, CMS also provides the following directives as part of the listed items in Chapter V Summary page:
A clarification has been added to the No-Fault Insurance Limit field (61), and to the CP11 error code, to indicate that you cannot add zeros as valid values if the Plan Insurance Type is “D” (No-Fault Insurance) for MSP submissions (Appendix A, Appendix F)
Of significance, the above guidance is a substantive change which is being published for the first time. From a technical perspective, this CP11 error/field 61 update is the only truly noteworthy change in the Version 6.3 update to the guide. Prior to the release of NGHP User Guide (Version 6.3), CMS would not reject a record with a “CP11” error when a zero-dollar amount value was submitted for the no-fault insurance limit (field 61) when the plan insurance type reflected a value of “D” indicating no-fault insurance. That has now changed and the “CP11” error will be generated in these scenarios moving forward. This change would appear to be effective immediately.
While not specifically listed in the Chapter V Summary page, the authors have noted other minor changes made to the error code table found in Appendix F. First is the removal of the “(Effective April 5, 2021)” tag which had previously been present in the “Possible Cause” column for all of the codes formerly labeled as “soft errors”. Second is the removal of the old “SP31” error from this table in its entirety. Then, finally, a correction has been made to the field number noted within the “Record Layout Field Description” and “Possible Cause” columns for error code “CS01”. Previously, the Plan Insurance Type value was referenced as being located in field 71. This was inaccurate and has been updated to reflect the proper field number for the Plan Insurance Type which is field 51.
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.
 CMS’s NGHP User Guide, Chapter III (Section 6.51, Page 6-22), Version 6.3, April 5, 2021.
As referenced by CMS, the TPOC computation is outlined in Chapter III section 6.4 and reads as follows:
The TPOC Amount refers to the dollar amount of a settlement, judgment, award, or other payment in addition to or apart from ORM. A TPOC generally reflects a “one-time” or “lump sum” settlement, judgment, award, or other payment intended to resolve or partially resolve a claim. It is the dollar amount of the total payment obligation to, or on behalf of the injured party in connection with the settlement, judgment, award, or other payment. Individual reimbursements paid for specific medical claims submitted to an RRE, paid due the RRE’s ORM for the claim, do not constitute separate TPOC amounts.
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.
The TPOC Date is not necessarily the payment date or check issue date. The TPOC Date is the date the payment obligation was established. This is the date the obligation is signed if there is a written agreement, unless court approval is required. If court approval is required, it is the later of the date the obligation is signed or the date of court approval. If there is no written agreement, it is the date the payment (or first payment if there will be multiple payments) is issued.
Note: Please refer to the definition of the TPOC Date and TPOC Amount in Fields 80 and 81 of the Claim Input File Detail Record in the NGHP User Guide Appendices Chapter V.
 See, CMS’s NGHP User Guide, Chapter III (Section 6.4, Page 6-13), Version 6.3, April 5, 2021.