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CMS releases Section 111 NGHP User Guide (Version 7.4) – updates include CMPs information and other general updates

The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 NGHP User Guide (Version 7.4, January 22, 2024) regarding Section 111 reporting related to non-group health plans (NGHPs) (liability, no-fault and workers’ compensation). 

  

As usual, CMS lists the new updates in the beginning of each User Guide chapter in a “Summary” page.  Reviewing these pages indicates that updates were made to Chapter I (Introduction and Overview), Chapter II (Registration Procedures), Chapter III (Policy Guidance), Chapter IV (Technical Information), and Chapter V (Appendices).  In general, as outlined below, CMS’s updates include the addition of a very general section regarding CMPs, along with several other updates and changes.

The following provides an overview of the changes made in NGHP User Guide (Version 7.4):

Section 111 Civil Money Penalties (CMPs)

CMS has added a new (and short) Section 5.1 in Chapter III titled “Civil Money Penalties” which provides general information regarding Section 111 CMPs.[1]

As part of this new section, CMS alerts the reader that it “has published regulations about the imposition of penalties related to noncompliance with reporting obligations, which can be found at 42 CFR §§ 402.1(c)(21)-(22)”[2] and that “NGHP RREs that fail to comply with these reporting requirements are subject to a CMP of up to $1,000, as adjusted for inflation for each calendar day of noncompliance. (Refer to 42 CFR § 102.3 for current CMP amount.).”[3]  The remainder of this new section essentially provides a general overview of limited CMPs items as outlined in 42 CFR §§ 402.1(c)(21)-(22), and as previously discussed by CMS, in much more detail, in its final rule document, Section 111 FAQ resource, and its January 18, 2024 webinar.

Overall, CMS outlines very general information regarding CMPs items in new Section 5.1 as follows:

CMPs - Timeliness

CMS notes that “[a]n RRE is deemed compliant where the RRE reported the MSP occurrence no later than 365 days after the RRE assumed primary payment responsibility or primary payment responsibility was otherwise demonstrated by a settlement, judgment, award, or other payment. In other words, RREs must report within one year of the date of incident, when ongoing responsibility for medicals (ORM) is assumed, or the TPOC date, or other operative dates when appropriate (for example, the beneficiary’s entitlement date if the beneficiary became entitled after ORM was assumed, or the ‘Funding delayed beyond TPOC date’ as further described in Section 6.5.1.1 below).”[4]

Records Review/Audit 

CMS reiterates information it has previously provided in its final rule and other CMPs releases stating as follows: “To drive compliance with the required reporting, CMS will select a randomized sample of 250 new MSP occurrences each quarter and audit these occurrences to determine whether RREs have complied with the reporting requirements for each of these occurrences … The occurrences to be audited will include both Section 111 submissions and records from sources outside of the Section 111 reporting process, to ensure that CMS does not miss those situations where an RRE has entirely failed to report the occurrence. RREs will only be informed when there is a potential instance of non-compliance.”[5]

Notice/Appeal

CMS provides general information regarding notice/appeal stating as follows: “RREs will be notified of potential non-compliance by CMS and afforded the opportunity to present information that demonstrates that the RRE was actually compliant. Such information will vary depending upon the situation, but may not include those situations where the RRE submitted records that CMS was unable to process due to the RRE’s file and record errors. Should CMS move forward with a potential CMP, a notice of proposed penalty will be issued. RREs should take note that the imposition of CMPs and appeals processes are separate and distinct from the initial determination and appeal rights for MSP debts. Should the RRE fail to request a hearing in response to the proposed penalty, or fail to successfully dispute the proposed penalty in the hearing, the penalty will be imposed.”[6]

Effective/Application Dates 

CMS states very generally that: “These regulations are effective as of December 11, 2023, and will be applied to RREs starting October 11, 2024.”[7] No further information was provided regarding this item in Section 5.1. However as noted in the next paragraph, CMS had provided further information regarding how CMS intends to apply the effective/application dates aspect of its final rule in general, and regarding which records may be in scope for penalties, in more detail in its previously released final rule and Section 111 FAQ resource, and as part of CMS’s recent January 18, 2024 webinar.

Authors’ Comments:  Regarding each item above, the authors again note that CMS has discussed each of these issues (and other CMPs items), especially how CMS intends to apply the effective/application dates aspect of its final rule  generally, regarding which records may be in scope for penalties, in more detail in its previously released final rule and Section 111 FAQ resource, and as part of CMS’s recent January 18, 2024 webinar.   Thus, the authors recommend that these additional resources also be reviewed for a more complete understanding of the above items, as well as other important CMPs issues which CMS has not referenced in Section 5.1.

Section 111 Extensions/Exemptions

CMS has added new verbiage to existing Section 6.5.1.1 in Chapter III.  This section is titled “Claims Related to Liability, No-Fault, and Workers’ Compensation.”  As part of this existing section, CMS outlines specific information and its reporting requirements regarding its TPOC (total payment obligation to the claimant) and ORM (on-going responsibility for medicals) reporting triggers as stated in full in the endnote to this sentence.[8]

To this already existing information, CMS has now added the following verbiage at the end of this section: “Note: There are certain specific circumstances under which CMS may grant extensions, exemptions, or otherwise alter the Section 111 reporting obligations. These situations are always at the discretion of CMS. The alternative reporting processes addressed by these extensions, exemptions, or alterations are considered by CMS to satisfy the S111 reporting requirements described within this user guide, where applicable.”[9]

While CMS did not provide any further information regarding why it has added this language to this particular User Guide section, it is possible that the CMS added this verbiage to comport with what the agency discussed on its recent webinar regarding what it referenced as Section 111 reporting exceptions regarding global resolution scenarios. 

On this point, as outlined in the author’s summary of CMS’s webinar, in the authors’ experience, CMS has historically agreed to sort out more complex global resolution scenarios and associated conditional payment recovery separate and apart from the Section 111 mandatory reporting process.  One of the more commonly occurring examples of such relates to a process referred to as AMP (Asbestos Malignancy Alternative Resolution Process).  When a global resolution is addressed with CMS in this fashion, outside its standard defined processes, the agency has granted an exception to the Section 111 reporting process for the claims in question and their associated RREs. 

With the above noted, during the webinar Q&A one webinar attendee asked whether these exceptions would continue to be honored and whether the associated RRE would be shielded from assessment of a CMP.  CMS responded by indicating that the newly published CMP regulations would not impact any of these prior or future agreements/exceptions.  In addition, CMS noted that it planned to publish more specific guidance in relation to these scenarios in an upcoming NGHP User Guide update.  Thus, it is possible that CMS has now added this new verbiage based on what it discussed and indicated on its webinar regarding global resolution scenarios as noted above. In the big picture, CMS’s addition of this verbiage is notable as these agreements and exceptions are not something regarding which CMS has published information on in the past and, as a result, the process has often seemed quite mysterious from the perspective of many NGHP RREs. 

Claim Input File updates

CMS has made updates to the Claim Input File (Chapter V).  Specifically, CMS states as follows: “CMS Field18 in the Claim Input File Detail description was corrected to note that ICD-10 codes beginning with “Z” may not be submitted on Section 111 reports (Appendix A). Parentheses are allowed in DBA Name (Field 48) and Legal Name (Field 49) in the Claim Input File Detail record (Appendix A).”[10] 

From the authors’ view, both of these updates appear to be additional clarifications added to the Claim Input File layout and are not indicative of changes to any prior reporting requirements.  In this regard, Field 18 refers to ICD Diagnosis Code 1 and the information provided within the description for this field applies to all ICD Diagnosis Code fields (ICD Diagnosis Codes 1 -19, Fields 18 – 36).[11] Here, CMS has added clarification within the description column indicating that ICD-10 codes which begin with the letter “Z” are not accepted.[12]  Historically, ICD-10 codes beginning with the letter “Z” have not been accepted for purposes of Section 111 reporting and have not been included within CMS’s valid ICD-10 code listings which CMS publish specifically for use within the Section 111 reporting process.  This update simply makes note of that longstanding fact.

Regarding fields 48 (DBA Name) and 49 (Legal Name), CMS has updated the “Data Type” column of the file layout to indicate that parentheses are accepted characters in relation to these two fields which are utilized by RREs when reporting coverage involving self-insurance.[13]  Where the “Data Type” in prior versions of the guide had reflected a value of “Alpha-Numeric,” it has now been updated to reflect a value of “Alpha-Numeric Plus Parens.”[14]  Here, this also appears to simply be clarification added to indicate that parentheses are acceptable characters within each of these fields as opposed to a change to any prior formatting requirements. 

Updated instructions for signing up for CMS updates

CMS has updated its instructions regarding how someone can sign-up for CMS.gov website update notifications.[15]  A listing of the actual sections within each Chapter where CMS made these updates, as outlined by CMS, is provided in the endnote to this sentence.[16] Overall, CMS’s new instructions update the information contained in previous versions of the User Guide which related to a prior outdated version of the CMS website.[17]

Domain/E-Mail Updates

CMS also notes that it has updated e-mail references throughout the User Guide to reflect recent domain changes.  On this point, in the Summary update pages to Chapters I, II, III, and  IV, CMS states, in pertinent part, as follows:  “To ensure continuity of contact and reflect recent domain changes, e-mails have been updated throughout this User Guide.”[18] A listing of the actual sections within each Chapter impacted by this update, as outlined by CMS, is provided in the endnote to this sentence.[19]  In terms of this update, CMS has created to two new e-mail domains: “@mail.cms.hhs.gov” and “@bcrcgdit.com.”[20] Thus, CMS notes that e-mails from CMS or the BCRC may now come from the new “@mail.cms.hhs.gov” or “@bcrcgdit.com” domains, in addition to the existing “@cms.hhs.gov” domain.[21]

Other Updates

As for other updates, in line with the domain updates referenced above, CMS has updated the e-mail addresses for the CMS contacts referenced in its “Escalation Process” section.[22]  Also, CMS’s email address through which System-Generated emails will be sent via CMS’s process is changing from cobva@section111.cms.hhs.gov (old e-mail) to  COBVA@mail.cms.hhs.gov (new e-mail).[23]  

In addition, the authors note that CMS has made a number of other changes which are not specifically referenced within CMS’s Summary update pages.  For example, CMS has added file naming conventions for the Unsolicited Response Files which the agency returns via SFTP and HTTPS (Chapter IV, Sections 10.3 and 10.4). Specifically, CMS added file naming conventions for the Unsolicited Response Files which they return via SFTP (Section 10.3) and via HTTPS (Section 10.4) as noted below as follows:  Section 10.3 SFTP file naming convention added: Unsolicited Response: P#EFT.ON.Xnnnn.Rxxxxxxx.UNS.Dyymmdd.Thhmmsst.TXT[24] and Section 10.4 HTTPS file naming convention: Unsolicited Response: PCOB.BA.MR.NGHPUNS.RESP.Dccyymmdd.Thhmm####.TXT.[25] CMS has also updated outdated URLs regarding its Computer-Based Training (CBT), list of valid ICD-9 and ICD-10 codes, and its NGHP User Guide page.[26]

Questions?

Of course, do not hesitate to contact us if you have any questions.  Please feel free to also review Verisk’s Section 111 CMPs resources for more information on Section 111 CMPS.


[1] CMS’s newly added Section 5.1 reads, in full, as follows:

To enhance enforcement of the MSP provisions, the reporting provisions also include authority for CMS to impose civil money penalties (CMPs) against RREs that fail to comply with the reporting requirements. NGHP RREs that fail to comply with these reporting requirements are subject to a CMP of up to $1,000, as adjusted for inflation for each calendar day of noncompliance. (Refer to 42 CFR § 102.3 for current CMP amount.) CMS has published regulations about the imposition of penalties related to noncompliance with reporting obligations, which can be found at 42 CFR §§ 402.1(c)(21)-(22). These regulations are effective as of December 11, 2023, and will be applied to RREs starting October 11, 2024.

To drive compliance with the required reporting, CMS will select a randomized sample of 250 new MSP occurrences each quarter and audit these occurrences to determine whether RREs have complied with the reporting requirements for each of these occurrences. An RRE is deemed compliant where the RRE reported the MSP occurrence no later than 365 days after the RRE assumed primary payment responsibility or primary payment responsibility was otherwise demonstrated by a settlement, judgment, award, or other payment. In other words, RREs must report within one year of the date of incident, when ongoing responsibility for medicals (ORM) is assumed, or the TPOC date, or other operative dates when appropriate (for example, the beneficiary’s entitlement date if the beneficiary became entitled after ORM was assumed, or the “Funding delayed beyond TPOC date” as further described in Section 6.5.1.2 below).

The occurrences to be audited will include both Section 111 submissions and records from sources outside of the Section 111 reporting process, to ensure that CMS does not miss those situations where an RRE has entirely failed to report the occurrence. RREs will only be informed when there is a potential instance of non-compliance.

RREs will be notified of potential non-compliance by CMS and afforded the opportunity to present information that demonstrates that the RRE was actually compliant. Such information will vary depending upon the situation, but may not include those situations where the RRE submitted records that CMS was unable to process due to the RRE’s file and record errors.

Should CMS move forward with a potential CMP, a notice of proposed penalty will be issued. RREs should take note that the imposition of CMPs and appeals processes are separate and distinct from the initial determination and appeal rights for MSP debts. Should the RRE fail to request a hearing in response to the proposed penalty, or fail to successfully dispute the proposed penalty in the hearing, the penalty will be imposed.

CMS’s Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter III, Section 5.1.

[2] CMS’s Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter III, Section 5.1.

[3] Id.

[4]Id.

[5] Id.

[6]Id.

[7] Id.

[8] Section 6.5.1.1 states, in full, as follows:

Information is to be reported for claims related to liability insurance (including self-insurance), no-fault insurance, and workers’ compensation where the injured party is (or was) a Medicare beneficiary and medicals are claimed and/or released or the settlement, judgment, award, or other payment has the effect of releasing medicals.

RREs must report on no-fault insurance and workers’ compensation claims where the injured party is/was a Medicare beneficiary that are addressed/resolved (or partially addressed/resolved) through a settlement, judgment, award, or other payment with a TPOC Date on or after October 1, 2010, that meet the reporting thresholds, regardless of the assigned date for a particular RRE’s first submission. This reporting requirement date of October 1, 2010 applies to the TPOC Date (see the definition of Claim Input File Detail Record Field 80), NOT necessarily when the actual payment was made or the check was cut. A TPOC is reported in total regardless of whether it is funded through a single payment, an annuity or as a structured settlement. See Section 6.4.1 for TPOC reporting thresholds.

RREs must report on liability insurance (including self-insurance) claims, where the injured party is/was a Medicare beneficiary that are addressed/resolved (or partially addressed/resolved) through a settlement, judgment, award or other payment with a TPOC Date on or after October 1, 2011, that meet the reporting thresholds, regardless of the assigned date for a particular RREs first submission. This reporting requirement date of October 1, 2011 applies to the TPOC Date (see the definition of Claim Input File Detail Record Field 80), NOT necessarily when the actual payment was made or check was cut. A TPOC is reported in total regardless of whether it is funded through a single payment, an annuity or a structured settlement. See Section 6.4.1 for TPOC reporting thresholds.

RREs must report no-fault insurance, workers’ compensation, and liability insurance (including self-insurance) claim information where ongoing responsibility for medicals (ORM) related to a claim was assumed on or after January 1, 2010. In addition, RREs must report claim information for claims considered open by the RRE where ongoing responsibility for medicals exist on or through January 1, 2010, regardless of the date of an initial assumption of ORM (the assumption of ORM predates January 1, 2010). See Section 6.3 (Ongoing Responsibility for Medicals (ORM) Reporting) and Section 6.3.1 for special exemptions and exceptions for reporting claims with ORM. Reporting is optional for certain liability insurance claims where there is no ORM (see Section 6.2.5 in Chapter IV).

RREs are to report after there has been a TPOC settlement, judgment, award, or other payment and/or after ORM has been assumed.

Note: There are certain specific circumstances under which CMS may grant extensions, exemptions, or otherwise alter the Section 111 reporting obligations. These situations are always at the discretion of CMS. The alternative reporting processes addressed by these extensions, exemptions, or alterations are considered by CMS to satisfy the S111 reporting requirements described within this user guide, where applicable. 

CMS’s Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter III, Section 6.5.1.,1 (CMS emphasis).

[9] CMS’s Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter III, Section 6.5.1.1.

[10] Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter V, Summary of Version 7.4 Updates, p. 1-1. Regarding these changes, the authors noted that CMS updated Field 18 (ICD Diagnosis Code 1 Description Field) in Appendix A of Chapter V to note that ICD-10 codes cannot begin with the letter “Z.” Noting this update, Appendix A now reads, in pertinent part, as follows:  See the NGHP User Guide Technical Information Chapter (Section 6.2.5) for complete information. ICD-9 codes cannot begin with the letter “E” and cannot begin with the letter “V.” ICD-10 codes cannot begin with the letters “V,” “W,” “X,” “Y,” or “Z.” Codes used here must NOT be on the list of Excluded ICD-9/ICD-10 Diagnosis Codes found on CMS.gov at https://www.cms.gov/medicare/coordination-benefits-recovery-overview/icd-code-lists.  Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter V, Appendix A.   In addition,  CMS updated Fields 48 and 49 to read that “Data type updated from “Alpha-Numeric” to “Alpha-Numeric Plus Parens.” Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter V, Appendix A.  Overall, this is just and update to the data type (e.g., data formatting) for both these fields).  In the big picture, from the authors’ perspective, the updates made to Fields 18, 48, and 49 can be viewed as minor points of clarifications versus actual technical changes.

[11] CMS’s Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter V, Appendix A.

[12] Id.

[13] Id.

[14] Id.

[15] CMS notes this change in the Summary update page to Chapters I, II, III, IV, and V which is contained at p.1-1 in each noted Chapter version.  

[16] CMS, as part of the updates noted in the respective Summary update pages to Chapters I, II, II, IV, and V, provides the following information where this new information can be found:

Chapter I:  Chapters 2, 8, and 9.  (Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter I, Summary of Version 7.4 Updates, p. 1-1.)

Chapter II:  Chapters 7 and 8. (Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter II, Summary of Version 7.4 Updates, p. 1-1.).

Chapter III:  Chapters 2 and 8, and Section 6.6. (Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter III, Summary of Version 7.4 Updates, p. 1-1.)

Chapter IV: Chapters 2, 13, and 14. (Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter IV, Summary of Version 7.4 Updates, p. 1-1.)

Chapter V: Chapter 2. (Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter V, Summary of Version 7.4 Updates, p. 1-1.)

[17] By way of example, CMS’s prior instructions referenced in NGHP User Guide Version 7.3 stated as follows:

Please be sure to visit the Section 111 page on the CMS web site at https://go.cms.gov/mirnghp frequently for updated information on Section 111 reporting requirements including updates to this guide. In order to be notified via email of updates to this web page, click on the Subscription Sign-up for Mandatory Insurer Reporting (NGHP) Web Page Update Notification link found in the Related Links section of the web page and add your email address to the distribution list. When new information regarding mandatory insurer reporting for NGHPs is available, you will be notified. These announcements will also be posted to the NGHP What’s New page.  Section 111 NGHP User Guide (Version 7.3, August 7, 2023), Chapter I, Section 8.

CMS’s new instructions as contained  in NGHP User Guide Version 7.4 reads as follows (with the authors underlining the updated text as provided by CMS for the reader’s convenience):

Please be sure to visit the Section 111 page on the CMS website at https://go.cms.gov/mirnghp frequently for updated information on Section 111 reporting requirements including updates to this guide. To be notified via email of updates to this or any CMS.gov webpage, enter your email address in the “Get email updates” section at the bottom of any CMS.gov webpage, and choose which topics for which you want updates. When new information regarding those topics is available, you will be notified. These announcements will also be posted to the NGHP What’s New page.  See e.g., Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter I, Section 8. 

[18] As noted, this statement was included in the Summary update page to Chapters I, II, III, and IV which is contained at p.1-1 in each noted Chapter version. 

[19] CMS, as part of the updates noted in the respective Summary update pages to Chapters I, II, II, IV, and V, provides the following information where this new information can be found:

Chapter I:  Chapters 7 and 8.  (Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter I, Summary of Version 7.4 Updates, p. 1-1.)

Chapter II:  Chapters 6 and 7. (Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter II, Summary of Version 7.4 Updates, p. 1-1.).

Chapter III:  Section 6.6. (Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter III, Summary of Version 7.4 Updates, p. 1-1.)

Chapter IV: Chapters 6 and 7. (Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter 1, Summary of Version 7.4 Updates, p. 1-1.)

[20] CMS’s Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter I, Section 8.

[21] CMS’s Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter I, Section 8.   On this point, CMS states:  Please note that emails from CMS or the BCRC may come from @mail.cms.hhs.gov, @cms.hhs.gov, and @bcrcgdit.com addresses. Please update your spam filter software to allow receipt of these email addresses.  Id.

[22]  CMS’s Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter I, Section 8.2.

a href="#_ednref23" name="_edn23">[23] CMS’s Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter I, Section 7.

[24] CMS’s Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter IV, Section 10.3.

[25]  CMS’s Section 111 NGHP User Guide (Version 7.4, January 22, 2024), Chapter IV, Section 10.4.

[26]  With respect to these updates, the authors outline the following for the reader’s convenience:


Mark Popolizio, J.D.

Mark Popolizio, J.D., is vice president of MSP compliance, Casualty Solutions at Verisk. You can contact Mark at mpopolizio@verisk.com.

Jeremy Farquhar

Jeremy Farquhar is a senior product consultant, Casualty Solutions at Verisk. You can contact Jeremy at Jeremy.Farquhar@verisk.com.


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