CMS Releases Updated Section 111 User Guide

The Centers for Medicare & Medicaid Services (CMS) released an updated NGHP User Guide to coincide with last week’s launch of the new “soft edit” process in Section 111 reporting.  The updated User Guide is heavy on technical changes associated with “soft edits,” but there is one under-the-radar update that will have immediate impact to workers’ compensation claims payers.

What are the Technical Changes?

Version 6.3 reflects the finalization of a number of key technical changes that had been previously announced. As previously described in detail, the new “soft edits” feature will mean that many data fields that are non-consequential in a recovery claim will no longer cause a rejection.  Additionally, an “SP31” error will no longer be returned if a claimant is not yet receiving Medicare benefits at the time a claim is reported.  Instead, an “03” disposition will be returned.  The CMS response file will now return an “CP13” error whenever a no-fault policy limit of less than $1,000 is reported.  An CP13 error will not result in the rejection of the claim record but will simply be returned to the RRE to ensure that the proper information has been reported.

What is the Workers’ Compensation Policy Clarification?

Last year, CMS updated its policy to clarify that indemnity-only workers’ compensation settlements and similar non-medical awards were not to be reported as total payment obligations to the claimant (TPOC).  CMS did not, at the time, provide any insight as to whether these prior settlements, judgments, or awards should be incorporated into a TPOC amount when the claim eventually settles (inclusive of medical).

Version 6.3 includes updated language to address this ambiguity, as follows: “The periodic payments or one-time settlement to compensate for lost wages are not reported as TPOCs, but may be included to compute the total TPOC amount.”  Interestingly, CMS provides a degree of some discretion.  Claims payers “may” include prior indemnity-only settlements as part of TPOC.  Presumably, those claims payers “may not” as well.  Essentially, it would seem, CMS is comfortable with claims payers including prior indemnity-only settlements and awards in the TPOC amount, but it is just as comfortable if claims payers exclude those amounts.

ECS will continue to closely monitor any Section 111 reporting changes and outline the critical context of those reporting changes to you.  Contact us today to learn more about how these changes may impact your claims process, or to learn more about our tailored Section 111 reporting solutions. Our Mandatory Insurer Reporting Team can be reached at MIRService.Support@examworkscompliance.com or 678-222-5454 to schedule an evaluation today

Marty Cassavoy

Marty Cassavoy

Marty Cassavoy is the Vice President of MSP Compliance at ExamWorks Compliance Solutions. Marty and his team develop solutions to challenges in all areas of Medicare Secondary Payer compliance and across all insurance types. An attorney licensed to practice law in Massachusetts, Marty works out of ExamWorks’ Woburn, Massachusetts office and can be reached at 781-517-8085 or martin.cassavoy@ExamWorksCompliance.com

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