New Year, New Section 111 User Guide
Last Updated: 26 Jan 2021
Author: Logan Pry, Compliance Manager
CMS has started off 2021 with a bang. As we have seen over recent months, CMS has been rapidly updating the NGHP Section 111 User Guide, releasing version 6.0 on Oct. 5, 2020 quickly followed by version 6.1 on November 10, 2020, and now version 6.2 in January. Unlike some past iterations of the User Guide, this release provides a few crucial updates that could affect RREs in a big way.
In sum, CMS has made a handful of changes, including permitting RREs to report an ORM termination date of up to 75 years in the future (previously, RREs were only permitted to report an ORM term date up to 6 months in advance or be subject to error). The Policy Number field is now considered a ‘Key Field’ for submitting updates and delete records. That is, in order for CMS to successfully update or delete a previously reported record, the policy number must match exactly to that of the previously accepted claim. This has an additional impact on the action type field for reporting purposes- in the event that an RRE needs to update a policy number on a previously accepted claim, it must submit the action type as a delete/add as opposed to an update record.
Further, CMS has issued updates changing one of the methods of data transmission, eliminating a past option for data transfer and replacing with a new option. CMS has also confirmed that the threshold for trauma-based liability insurance settlements, no-fault insurance, and workers’ compensation settlements will remain at $750 so long as there is no ORM. Finally, a retraction has been issued. CMS previously announced that error code CP03 (an error in the office code field) would trigger a ‘soft error’, this error will no longer be considered a soft error and will be considered in triggering the error threshold on a claim input file.
These updates also indicate that at least one more iteration of the User Guide will be coming in April of this year.
A full summary of updates, as provided by CMS in version 6.2, as well as the section in which these updates are found are as follows:
- As part of CMS’ commitment to the modernization of the Coordination of Benefits & Recovery (COB&R) operating environment, changes are being implemented to move certain electronic file transfer data exchanges to the CMS Enterprise File Transfer (EFT) protocol. As part of this change the exchange of data with the COB&R program via Connect:Direct to GHINY SNODE will be discontinued. The final cutover is targeted to occur in April 2021. File naming conventions and other references have been updated in this guide. Contact your EDI Representative for details (Section 4.2.4).
- As of January 1, 2021, the threshold for physical trauma-based liability insurance 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 (Sections 6.4.2, 6.4.3, and 6.4.4).
- To address situations where Responsible Report Entities (RREs) can identify future ORM termination dates based on terms of the insurance contact, RREs can now enter a future Ongoing Responsibility for Medicals (ORM) Termination Date (Field 79) up to 75 years from the current date (Section 6.7.1).
- As seen in Ch. II above - changes are being implemented to move certain electronic file transfer data exchanges to the CMS Enterprise File Transfer (EFT) protocol. As part of this change the exchange of data with the COB&R program via Connect:Direct to GHINY SNODE will be discontinued. The final cutover is targeted to occur in April 2021. File naming conventions and other references have been updated in this guide. Contact your EDI Representative for details (Sections 10.2 and 10.3).
- As seen in Ch. III above - as of January 1, 2021, the threshold for physical trauma-based liability insurance 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 (Sections 6.4.2, 6.4.3, and 6.4.4).
- To support previous system changes, Policy Number (Field 54) has been added as a key field. If this field changes, RREs must submit a delete Claim Input File record that matches the previously accepted add record, followed by a new add record with the changed information (i.e., delete/add process) (Sections 6.1.2, 6.6.1, 6.6.2, and 6.6.4).
- As seen in Ch. IV above – Responsible Reporting Entities (RREs) can now enter a future Ongoing Responsibility for Medicals (ORM) Termination Date (Field 79) up to 75 years from the current date (Appendix A and Appendix F).
- In Version 6.1, we announced that several input errors will become “soft” errors starting April 5, 2021. However, CP03 will not become a soft edit. The Office Code/Site ID (Field 53), which triggers CP03, is used to identify correspondence addresses, and if incorrect, could result in mail being sent to the wrong place. Therefore, this error will continue to reject the record (Appendix F).
Version 6.2 of the User Guide in its entirety can be found here:
The PAID Act:
This release comes on the heels of the PAID Act being signed into law on December 11, 2020. In short, the PAID Act expands the Section 111 Medicare query process to require CMS to provide an RRE with any Medicare Part C and/or Part D entitlement information within the preceding 3-year lookback period. In addition to entitlement information, if applicable, the RRE must also be provided with the names and addresses of those plans. While version 6.2 of the NGHP User Guide does not yet address the mandatory updates outlined by the PAID Act, the rapid review and amendment of the User Guide seems to imply that it is on CMS’ radar, not to mention that the PAID Act specifically states that the updates to the Section 111 Query process must be in place by December 2021. This tight timeline indicates that there will be more information to come regarding changes to the Section 111 process.
In light of this release and the PAID Act being signed into law, it is becoming increasingly more important to ensure that your Section 111 reporting program is in compliance with CMS’ current guidance. Areas of focus should include ensuring that claims that meet all applicable reporting thresholds are reported in a timely manner, that claims are reported error-free, and that conflicting information is not being provided.
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, Civil Monetary Penalties, the PAID Act, and how we can assist you with an internal audit and ensure your Section 111 reporting remains compliant.
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