The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 NGHP 270/271 Companion Guide Version 5.7, August 6, 2021 (also referenced herein as “Companion Guide”) as part of its PAID Act implementation plans. Version 5.7 of the Companion Guide replaces Version 5.6 which CMS published on July 22, 2021. See our prior article for the changes made by CMS in Version 5.6.
As a refresher, pursuant to the PAID Act, CMS will be providing RREs with the following information through the Query Response File: The contract number, contract name, plan number, coordination of benefits (COB) address, and entitlement dates for the last three years (up to 12 instances) regarding a claimant’s Medicare Part C (Medicare Advantage) and Part D (prescription drug) coverage. In addition, CMS will be providing the most recent Part A and Part B entitlement dates. The PAID Act implementation is scheduled to go-live on December 11, 2021.
Regarding CMS’s Companion Guide, this has been in existence since the start of the Section 111 reporting process and is intended for use by RREs who choose to utilize their own EDI translator software to perform their X12 270/271 translation and not the HIPPA Eligibility Wrapper (HEW) software which CMS makes available free of charge. Historically, CMS has published this Companion Guide in conjunction with the file layout specifications utilized for their HEW Software process as outlined by CMS in the Section 111 NGHP User Guide, Chapter V (Appendix E).
Version 5.7 of the Companion Guide makes further updates to the EDI X12 271 mapping for the expanded query response data elements that are being added as a part of CMS’s PAID Act implementation.
CMS describes the changes made in Version 5.7 of the Companion Guide as follows:
For this release, the Part C Medicare Advantage and Part D Prescription Drug Enrollment Data 271 eligibility response file tables have been updated to display the correct Segment IDs for Element IDs NM101-103. Additionally, Part D contract information has been added (Table 26 and Table 2). Other changes have also been made to update and reorganize several tables.
In terms of impact, as noted above, the changes made in Companion Guide Version 5.7 relate only to those RREs who choose to utilize their own EDI translator software as opposed to CMS’s free HEW application. To the extent any of these reporters had already started to make coding changes based off Version 5.5 or 5.6 of the Companion Guide, adjustments may be now required per CMS’s corrections as stated in Version 5.7. For those reporters who had not yet applied the changes contained in Versions 5.5 and 5.6, they should reference Version 5.7 of the Companion Guide for CMS’s updated guidance.
Finally, for those readers interested in learning more about the PAID Act and CMS’s implementation plans, see our recent articles CMS discusses PAID Act implementation plans and timelines on webinar and PAID Act – current status and FAQs.
Of course, please do not hesitate to contact the authors if you have any questions. Also, feel free to contact the authors if you have any questions regarding the latest updates on the PAID Act.
 The authors note that the full name of this guide is “270/271 Health Care Eligibility Benefit Inquiry and Response Companion Guide for Mandatory Reporting Non-GHP Entities. However, in practice this resource is commonly abbreviated. In this regard, the authors reference this guide as the “Section 111 NGHP 270/271 Companion Guide” or simply as the “Companion Guide.”
CMS states the “purpose” of this guide as follows:
This guide provides the Medicare COB System Interface Specifications for use by Medicare Secondary Payer (MSP) Non-GHP entities, e.g., liability insurance (including self-insurance), no-fault insurance and workers’ compensation Responsible Reporting Entities (RREs), reporting under Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA Section 111).
The process requirements detailed in this guide must be followed by Non-GHP entities in order to submit an eligibility benefit inquiry to the BCRC and receive an eligibility benefit response. This guide is intended to be used as a companion document to the National Electronic Data Interchange Transaction Set Implementation Guide and the Health Care Eligibility Benefit Inquiry and Response, ASC X12N 270/271 (005010X279A1) Implementation Guide. The specifications listed are clarifications that are allowed within established HIPAA transaction sets. The BCRC will only accept and send data in the allowed ASCX12 transaction format that is allowed by HIPAA regulations and guidelines.
This document does not outline all data segments and elements that are in the HIPAA transaction set guide. This document only addresses segments as they apply to the BCRC.
CMS’s Section 111 NGHP User Guide, Chapter IV (Version 6.4, June 11, 2021), Chapter 1, p. 1-1. (CMS emphasis).
 CMS’s Section 111 NGHP User Guide, Chapter IV (Version 6.4, June 11, 2021), Chapter 1, p. 1-1.