Two weeks in advance of its PAID Act webinar, CMS has released an updated NGHP Section 111 User Guide.  While the latest version contains several updates, the most intriguing and most impactful may be the announcement that the changes to the Medicare entitlement information provided via the Section 111 query process outlined by the PAID Act will be effective December 11 of this year. Moreover, we now know the exact information to be provided as well as the response file layout. We have known that these changes were on the horizon since the signing of the PAID Act on December 11 of last year. However, receiving this information in June gives RREs a few months to implement the requisite changes to their own system and process in order to properly utilize the additional information that will now be returned on the query response file.

As a quick refresher, the PAID Act, in relevant part, requires that CMS expand its Section 111 query response data in order to identify whether an individual is, or has been, entitled to, Medicare Part C and/or Part D benefits within the last three years. It also requires CMS to provide the plan name and contact info for any positive results returned through this process.

Given the growing body of case law providing favorable recovery rights to Medicare Advantage plans and their assignees under the private cause of action of the Medicare Secondary Payer Act, identifying any Medicare Advantage coverage overlap and resolving any potential liens prior to, or as a part of, your settlement can be critical.

Although the PAID Act updates make up the majority of the changes to version 6.4 of the User Guide, there were other very important updates and a summary of the changes is outlined below: 

• Ch. II Registration – added acknowledgement of the PAID Act – informative only – I.E., “Effective December 11, 2021, the Provide Accurate Information Directly Act (PAID Act) was passed to help Non-Group Health Plan (NGHP) Responsible Reporting Entities (RREs) better coordinate benefits by providing additional beneficiary enrollment information. With this Act, RREs will receive Part C (Medicare Advantage Plan) and Part D (Medicare prescription drug coverage) enrollment information for the past 3 years, as well as the most recent Part A and Part B entitlement dates, on the Query Response File (Chapter 3).”
• Ch. III Policy Guidance – added early ORM termination criteria. Specifically, this guidance permits an RRE to terminate ORM early in certain circumstances. The claim must meet all 4 prongs of the following: 
  • No claims were paid with any diagnosis codes related to alleged ingestion, implantation, or exposure; and
  • No claims were paid, for any medical item or service related to the case, within five (5) years of the date of service of any such claim; and
  • Treatment did not include, nor were any claims paid related to, a medical implantation or prosthetic device; and
  • The total amount paid by the insurer, for all medical claims related to the case, did not exceed $25,000.
  • Note: If, at any time, any of the parameters set forth above should no longer be applicable, the insurer must then update the ORM record to reflect that they, once again, have ongoing responsibility for medicals (i.e., update the termination date to all zeroes). Should the case once again fall under these parameters (for example, if five years elapse from the last relevant date of service), then ORM for that case may once again be terminated in accordance with the criteria above.
•  Ch. IV Technical Information –
  • Updated event table for partial settlements leaving one injury ORM open
  • Effective December 11, 2021:
    • PAID Act acknowledgement
    • Full layout of the query response file – including plan info, entitlement dates, contact info, for the last 3 years (for up to 12 instances) for parts C and D; update will also provide part A and B entitlement dates
  • Updated process for installing and configuring HEW software
• Ch. V Appendices –
  • SP55 error code added - MSP Effective Date is invalid or less than the earliest beneficiary Part A or Part B Entitlement Date
  • Effective December 11, 2021:
    • PAID Act acknowledgement
    • Full layout of the query response file – including plan info, entitlement dates, contact info, for the last 3 years (for up to 12 instances) for parts C and D; update will also provide part A and B entitlement dates
    • Updated process for installing and configuring HEW software

Don’t forget to register for Allan Koba Compliance Solution’s debriefing webinar on June 24^th discussing CMS’ PAID Act web conference, implementation of the changes being brought on by the PAID Act, and their effect on Section 111 reporting and conditional payment recovery. 

Email info@allankoba.com to register for the June 24^th Webinar. 

For any comments, questions, or concerns regarding the newest updates to the NGHP User Guide, the PAID Act implementation, updates on Civil Monetary Penalties, and Section 111 reporting and conditional payment recovery efforts in general, please don’t hesitate to contact our reporting team at section111@allankoba.com.