CMS Releases Updated NGHP Section 111 User Guide, Version 7.3
Last Updated: 22 Aug 2023
Author: Logan Pry
CMS has continued the recent onslaught of Section 111 Reporting updates with the release of the latest iteration of the Non-Group Health Plan User Guide – Version 7.3. Given other recent updates, alerts, and townhall conferences held, this does not come as a surprise. Version 7.3 contains three main revisions:
First, and arguably the most significant, Ch. III has been updated to attempt to add some detail to the section on Ongoing Responsibility for Medical (ORM) reporting - Section 6.3. These changes aim to clarify what triggers ORM. In a prior update, this section was expanded, adding a conjunctive, 2-part test for the trigger of ORM. That is, in Version 7.2, the trigger for ORM was the assumption of ORM by the RRE AND the beneficiary receiving medical treatment for the related injury. This update caused questions from our industry, including how and when an RRE should know about medical treatment. In response to these questions, the agency has released the updates of Version 7.3 which has removed use of the word “and”, applying a new definition which now states that the trigger for ORM reporting is the determination to assume ORM which is when the RRE learns, through normal due diligence, that the beneficiary has received claim-related treatment.
These changes to the text effectively remove the decision-making power from the RRE to decide when ORM has been accepted, and has defined acceptance as knowledge of claim-related treatment. That surely cannot be the intent of CMS here and I anticipate additional updates to follow. As an example, under this text, an RRE would be assuming ORM if they learn of treatment, through normal due diligence, in a denied claim. A case in which ORM would normally not be reported.
For comparison, the language of Section 6.3 now reads as follows:
The trigger for reporting ORM is the assumption of ORM by the RRE, which is when the RRE has made a determination to assume responsibility for ORM and when the beneficiary receives medical treatment related to the injury or illness. Medical payments do not actually have to be paid, nor does a claim need to be submitted, for ORM reporting to be required
The trigger for reporting ORM is the determination to assume ORM by the RRE, which is when the RRE learns, through normal due diligence, that the beneficiary has received (or is receiving) medical treatment related to the injury or illness sustained. Required reporting of ORM by the RRE does not necessarily require the RRE to have made payment for Medicare-covered items or services when the RRE assumed ORM, nor does a provider or supplier necessarily have to have submitted a claim for such items or services to the RRE for the RRE to assume ORM.
Second, Ch. IV has been updated to inform users who have opted into the unsolicited response file process that they may receive an empty file if no updates were made to their records in a given reporting period. That is, if an RRE has opted to receive the unsolicited response file, it will still receive a blank response file if no updates have been made by outside parties that would/should be contained therein. While the issuance of empty unsolicited response files was previously announced via an Alert last month, the fact that an empty file may be received is now outlined in Ch. IV, Sect. 7.5 for future reference.
Finally, so long, Internet Explorer. Chapters I, II, and IV have been revised to remove all references to Internet Explorer as it is no longer a supported browser. While this update likely does not make too many waves, it may be of interest to some carriers utilizing a reporting software that was designed for IE.
Each chapter of the updated User Guide, Version 7.3 is available for download here - https://www.cms.gov/medicare/coordination-of-benefits-and-recovery/mandatory-insurer-reporting-for-non-group-health-plans/nghp-user-guide/nghp-user-guide.
For questions about these updates, as well as general inquiries about Section 111 reporting and all things Medicare Secondary Payer, please contact us at firstname.lastname@example.org.
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