The Centers for Medicare and Medicaid Services (CMS) has issued a new Section 111 alert “reminder” regarding the reporting of personal injury protection (PIP), and Med-Pay policy limits on non-group health plan (NGHP) claim input files in situations where separate Med-Pay and PIP coverages being paid out under a single policy for the same injured party and incident. By way of note, CMS’s reporting instructions about this situation are currently referenced in the agency’s NGHP Section 111 User Guide, Version 5.8 (January 31, 2020), Chapter III: Policy Guidance, Section: 6.5 – Additional Requirements (Page: 6-20) and this new alert serves to reinforce these existing directives.
Through this new alert, CMS issues the following reminders regarding its existing policies:
- Both Med Pay and PIP coverage should be included when reporting the No-Fault Insurance Limit (Field 61 of Claim Input File). As such, CMS states that “NGHP RREs must combine both Med Pay and PIP coverage limits for a policy when they are separate coverages being paid out on claims for the same injured party and incident under a single policy.”
Regarding this directive, CMS indicates that it has recently come to their attention that some NGHP RREs are only including Med Pay when reporting the No-Fault Insurance Limit. However, in this situation, CMS advises that “[i]f both Med Pay and PIP coverage limits are not reported, then the amount reported is not an accurate reflection of the policy limit.” Further, CMS indicates that ongoing responsibility for medicals (ORM) should not terminate until both the Med Pay and PIP coverage limits are exhausted.
- CMS reminds the RRE that it is important “to accurately reflect two decimal places when reporting No-Fault Insurance Limit. For example, a policy limit of $5,000 should be reported as 500000.”
- Finally, CMS advises that additional information on these points can be found in its Section 111 NGHP User Guide, which is available on the NGHP User Guide page of CMS.gov.[1]
CMS’s new alert provides a nice opportunity for NGHP RREs to review their current practices to ensure they are properly reporting the exhaustion of policy limits in accord with CMS’s instructions in situations where separate Med-Pay and PIP coverages being paid out under a single policy for the same injured party and incident.
Of course, please do not hesitate to contact the authors if you have any questions regarding this alert or Section 111 reporting in general.
[1] See, CMS’s NGHP Section 111 User Guide, Version 5.8 (January 31, 2020), Chapter III: Policy Guidance, Section: 6.5 – Additional Requirements (Page: 6-20).
