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CMS Releases New NGHP Section 111 User Guide

 |  January 4, 2019

The Centers for Medicare and Medicaid Services (CMS) has updated its Non-Group Health Plan (NGHP) Section 111 User Guide. The new guide is styled as Version 5.5 and is dated January 7, 2019. Per CMS, changes were made to Chapters III and V of the guide, with no changes made to Chapters I, II or IV. 

These new updates include the following:

NGHP Section 111 User Guide (Version 5.5, January 7, 2019)

Chapter III Updates

CMS incorporated the information contained in its recent alert on the “low dollar” reporting threshold.  Specifically, in Section 6.4 CMS added the following verbiage documenting retention of its $750 reporting threshold as follows:

Beginning January 1, 2019, the threshold for liability insurance settlements, judgments, awards, or other payments (“settlements”) will remain at $750.  CMS will maintain the $750 threshold for no-fault insurance and workers’ compensation settlements, where the no-fault insurer or workers’ compensation entity does not otherwise have ongoing responsibly for medicals.

Please see ISO CP’s recent article on this matter as an additional resource. 

Chapter V Updates

CMS’s updates to Chapter V include:

  • TPOC Determined After Settlement Date:
    • If the Total Payment Obligation to Claimant (TPOC) is determined after the settlement date, Responsible Reporting Entities (RREs) are required to provide an actual or estimated date for the TPOC funding. To this end, the definitions for the Funding Delayed Beyond TPOC Start Date fields (and related error code descriptions) have been updated (Table A-3, fields 82, 95, 98, 101, and 104).
  • Updates to ICD-9 and ICD-10 Tables
    • To resolve discrepancies, the excluded ICD-9 and ICD-10 tables in the appendices have been updated to match the excluded lists that are available through the Section 111 MRA application (Appendix I and Appendix J).
  • Other
    • In addition to the above, CMS advised that to reduce the number of version and revision history pages, the guide now includes only information from the last four releases.

Please contact the author directly if you have any questions on these new updates at mpopolizio@verisk.com or 786-459-9117.