CMS Updates Section 111 NGHP User Guide

On Tuesday October 5th the Centers for Medicare & Medicaid Services (CMS) published version 6.5 of the NGHP User Guide. There are a number of substantive changes, although nothing earth-shattering.  As with prior key updates, ExamWorks Compliance Solutions is here to give you all the important details on what has changed in this version.

Here is a look at the key updates.

  • CMS has clarified the requirements for reporting claims where the CMS Date of Incident is prior to 12/5/1980. CMS added the following bullet point to the User Guide, “In cases where exposure has ended prior to December 5, 1980, and there is not yet a settlement, judgment, award, or other payment, it would be inappropriate, and counter to the MMSEA Section 111 reporting obligations, to report such a claim.”
    • We are pleased that CMS has made it this explicit statement to discourage over-reporting. This is a big change from some of the early conversations during Town Hall teleconferences in the early days of Section 111 reporting.  The simple fact is that over-reporting has negative downstream impacts including over-burdening claims staff and unnecessary conditional payment letters.  Challenges caused by over-reporting go far beyond exposure claims, of course, but CMS’ characterization of this type of over-reporting as “inappropriate” is a welcome language.
    • Exposure, Ingestion, and Implantation claims require special attention when it comes to Section 111 reporting. If you have any questions or concerns related to these types of claims, please reach out to us here.
  • CMS will now allow responsible reporting entities (RREs) using CMS’ Direct Date Entry (DDE) to use the beneficiary lookup feature on the Section 111 Coordination of Benefits website.
    • This change will allow RREs using DDE to access Medicare Advantage Plan (MAP) Data prior to the reporting of their claims. For RREs utilizing ECS for reporting, this change is negligible.
  • As previously covered by Scott Huber in an ECS Blog Post, CMS will now accept records 3 months prior to the Injured Party’s Medicare Entitlement date.
    • Previously, when a Medicare Eligible injured party was reported to CMS prior to the Medicare Entitlement Date, CMS would not process the claim and return a ‘03’ Disposition code. Now, if the injured party is within 3 months of the Medicare Entitlement Date, CMS will process the record and return the appropriate Disposition Code.
  • CMS updated TIN Reference Response File processing as the result of a change in TN30 logic.
    • The TN30 error (Recovery Agent zip+4) is still returned when applicable. However, CMS will no longer reject a record as the result of a TN30 error.
  • CMS added previously published details related to the data that will be returned as part of the PAID Act. ECS has covered the PAID Act in multiple Blog posts. CMS will start providing back data for Part C and Part D per the PAID Act as of December 11, 2021. ECS is ready; are you?
  • CMS updated the descriptions to several input errors that no longer cause a submitted record to be rejected.
    • The column titled “Description” on the Appendix C and Appendix D tables have been updated to better reflect the changes CMS made earlier this year.
  • CMS has updated the ICD-10 Diagnosis codes for FY 2022. The new list can be found under the tab Reference Materials here. ECS will update its reporting logic to adjust for this annual update prior to the start of 2022.
  • CMS updated the HEW Translation table and corrected the HEW Query Input file layout.
    • This another negligible change for any RRE that is not submitting data directly to CMS.

What does this all mean?

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 about your program today

Matt Stonehouse

Matt Stonehouse

Matt Stonehouse is the MMSEA Business Analyst at ExamWorks Compliance Solutions. Matt oversees MMSEA Auditing while serving as the internal Business Analyst for ECS’ industry leading reporting solution. A native Floridian, Matt has been with ECS since 2009 and has an extensive background in MMSEA and MSP Compliance.

Matt can be reached at 678-256-5127 or Matthew.Stonehouse@ExamWorksCompliance.com