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CMS releases new NGHP Section 111 User Guide (Version 6.1) and Technical Alert

The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 NGHP User Guide (Version 6.1, November 10, 2020) regarding non-group health plans (liability, no-fault, and workers’ compensation). This updated guide replaces Version 6.0 (October 5, 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 IV (Technical Guidance) and Chapter V (Appendices). These changes, as highlighted more generally below, relate to the eventual elimination of the ‘SP31’ error notice, certain current input record errors becoming “soft errors” no longer causing record rejection, and a new “soft” edit regarding no-fault insurance claims where the policy limit is less than $1,000.00.

CMS also released a new technical alert (November 12, 2020). While this alert bears a later date than the new User Guide, the updates made in this alert relate to CMS’s plans to make certain current input records “soft errors.” The updates here are essentially the same updates made about this item in Chapter V of the new User Guide. CMS noted this in the technical alert, stating the changes there also reflect the changes found in the new User Guide. As such, it is unclear why CMS issued this separate alert.

CMS’s newly released Section 111 NGHP User Guide made changes to Chapter IV and V on error notices.

The following provides a general overview of the updates made by CMS in User Guide (Version 6.1):

CMS to eliminate the ‘SP31’ error notice (records submitted before Medicare entitlement) starting April 5, 2021

In Chapter IV (Technical Guidance) of the new User Guide, CMS notes that it is eliminating the current ‘SP31’ error notice effective April 5, 2021. An ‘SP31’ error is currently returned in circumstances where a record is submitted prior to the effective date of the beneficiary’s Medicare entitlement. At present, upon receipt of an ‘SP31’ error, no corrections are required by the RRE. Instead, CMS instructs RREs to resubmit the same record on their next quarterly submission. Moving forward, CMS has indicated that they will continue to reject these records received before Medicare beneficiary’s entitlement date but that they will return an ‘03’ disposition rather than the ‘SP31’ error. 

CMS describes this update more fully in the “Summary” update page contained in Chapter IV (Technical Guidance) as follows:

Starting April 5, 2021, the following change will become effective:

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. 

Certain Section 111 input records errors that would cause a record to reject will become “soft errors” starting April 5, 2021

In Chapter V (Appendices) of the new User Guide, CMS indicates that numerous error codes that have historically resulted in the rejection of a record will become “soft error” codes and will no longer result in the record being rejected. However, CMS notes that RREs will continue to receive the errors on their response files and should correct and resubmit on their next quarterly submission.

Further, CMS notes that a new “soft” edit will be 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 $1,000.00. The input files will be accepted in this instance, but a new CP13 error will be returned on the response files. CMS indicates that 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.

CMS describes these updates more fully in the “Summary” update page contained in Chapter V (Appendices) as follows:

Starting April 5, 2021, the following changes will become effective:

  • A new “soft” edit will be 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 $1,000.00. The input files will be accepted but a new CP13 error will be returned on the response files. 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).
  • Several Section 111 input record errors that would cause a record to reject will become “soft” errors; that is, they 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, CP03, 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).

Our review of the error codes noted above in the second bullet noted as being changed to “soft edits” encompass:

  • Additional Claimant info including Claimant Middle Initials, Claimant Zip+4, Claimant Phone, and Claimant Phone Extension
  • Representative and Claimant Representative information including the Zip+4, Phone, and Phone Extension fields
  • Industry Date of Incident, Alleged Cause of Injury, Office Code/Site ID fields, and all Plan Contact related fields 

Questions?

Please contact Jeremy Farquhar at jeremy.farquhar@iso.com if you have any questions regarding the above updates or general Section 111 questions.


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 Farquhar@verisk.com.


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