On October 7^th, CMS released Version 7.7 of the MMSEA NGHP User Guide with a few key updates. This iteration adds additional information regarding the steps needed and the emails that are issued during RRE registration, specifically Ch. 1 Table 7-1, Ch. 2 Table 6-4, and Ch. 4 Table 12-1. In general, these tables provide an easy-to-read overview of the registration process from TIN input, to PIN verification, and RRE vetting. Version 7.7 also adds some clarity to the reporting of wrongful death claims. Ch. 3 has added a note indicating –

“Settlements, judgments, awards, or other payments obtained entirely under the wrongful death theory of liability, which do not claim and release medicals, or have the effect of releasing medicals, are not required to be reported because Medicare would have no recovery claim against such a payment.”

However, the headline for this update is that CMS has added a warning flag for late reporting of claims reflecting open ORM. Chapters 4 and 5 both note that waring flag 04 has been added. This warning flag will be applied to claim response files with open ORM records, when the later date of either the CMS Date of Incident on the claim record, or the Part A Add Date is greater than 135 calendar days from the Start Date of the RRE's submission period. Said differently, warning flag 04 will be applied to claims with open ORM that are reported more than 135 days after the DOI (or after the first date of entitlement for claims in which ORM was open prior to Medicare eligibility).

Prior to this release, CMS did not have a mechanism for providing RREs with a response warning indicating potential late reporting for claims with open ORM. In the past, RREs would receive a compliance flag (now called “warning flags”) for reporting a TPOC Date or an ORM termination date more than 135 days after its occurrence. This new warning flag provides RREs with an indication that the report, while accepted and reflecting ORM, was submitted more than 135 days after its occurrence.

As a reminder, the period for claims that may be assessed a civil monetary penalty begins in just a few days, and while an NGHP record must be more than 365 days late in order to be possibly subject to penalty, these warning flags serve as a reminder that if reporting is delayed, you put yourself at risk for CMP. As a best practice, RREs should ensure that they are reporting all claims that meet all applicable reporting thresholds error free and in a timely manner. In order to help ensure that you mitigate risk, and identify problem areas, an internal diagnostic review can be an invaluable tool. Through a review of your policies and procedures, your reporting system logic, and through a selection of claims, RREs are able to identify problem areas that may expose them to penalties or downstream liabilities if not addressed. This could include, but is certainly not limited to, late collection of query information or false negative query results, inaccurate diagnostic coding, late or improper entry of ORM, ORM term, and/or TPOC information, as well as system issues preventing proper reporting or failing to alert your team members to issues that need to be resolved.

For question, concerns, and comments about the recent User Guide updates, designing a diagnostic review, as well as general inquiries about Section 111 Reporting compliance please contact us at info@allankoba.com.