Section 111 User Guide Update

Last Updated: 16 Apr 2021

Author: Logan Pry

In the fourth iteration of the NGHP Section 111 User Guide in six months, CMS has issued several updates, mainly affecting technical aspects of Section 111 reporting. The bulk of these updates attempt to clarify how and when errors will be received through the reporting process. As we know, the proposed regulations regarding civil monetary penalties put out last year, with public comment period running through April 2020, outlined an ‘error threshold’ as a possible way for an RRE to be penalized for noncompliance. The continued updates on Section 111 errors and clarification on the same seems to indicate that CMS still has CMPs and specifically, the error threshold, in its crosshairs.  

In short, version 6.3 of the User Guide provides clarification that individual payments to account for lost wages are not individual TPOC events; it confirms an extensive list of ‘soft errors’ (i.e. errors that will not cause a claim input file to be rejected due to error threshold, but should still be corrected and resubmitted); it confirms that error code CP13 for no-fault limit is now effective (as of 4/5/21); it confirms the elimination of the SP31 disposition code in favor of disposition code 03 in the event that a record is submitted prior to the individual’s date of entitlement; and finally, it adds clarification to the CP11 error for reporting no-fault insurance limit.

A full summary of updates in version 6.3 of the User Guide, as well as the section in which these updates are found are as follows: 

Ch. III

  • To align with the terms and conditions regarding the acceptance of Ongoing Responsibility for Medicals (ORM) as described in Section 6.4, the language around periodic payments or one-time settlements to compensate for lost wages has been clarified (Section 6.5.1).

Ch. IV

  • Several Section 111 input record errors that would cause a record to reject 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, 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 (Section 7.1 and NGHP Chapter V).
  • 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 (Section 7.2).

Ch. V

  • Several Section 111 input record errors that would cause a record to reject 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, 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).
  • A new edit has been 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 $1000.00. The input files will be accepted but a new CP13 error will be returned on the response files to notify users to confirm the dollar amount submitted. 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).
  • 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.
  • A clarification has been added to the No-Fault Insurance Limit field (61), and to the CP11 error code, to indicate that you cannot add zeros as valid values if the Plan Insurance Type is “D” (No-Fault Insurance) for MSP submissions (Appendix A, Appendix F).

 

Version 6.3 of the User Guide in its entirety can be found 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

 

Allan Koba continues to stay committed to bringing you the latest updates from CMS on all things MSP compliance. Please contact our Section 111 Reporting team at Section111@allankoba.com to discuss the newest updates to the NGHP User Guide and Section 111 reporting in general, updates on Civil Monetary Penalties, changes to Section 111 reporting as a result of the PAID Act, and how we can assist you with a Section 111 Diagnostic Evaluation to ensure your Section 111 reporting remains compliant.

 

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