CMS Unleashes New User Guide Updates – Brace for Some Massive Shifts

The T-rex is not the only thing roaring into 2025 – CMS released an updated NGHP User Guide (version 8.2), and the policy changes are significant. While not quite the next Jurassic Park sequel, the updates will impact liability carriers, workers’ compensation payers, and anyone navigating Section 111 and mandatory WCMSA reporting. 

And like any good movie trailer, this update arrives with unintended consequences. Recent challenges with WCMSA reporting appear to have forced CMS’ hand, prompting several key shifts in how RREs report settlements.  

Important Policy Changes

CMS updated its guidance regarding joint settlements and multiple settlements involving the same individual and it added new language regarding single settlements resolving multiple incidents and MSAs. All in all, CMS clarified three major areas. Let’s unpack each.

1)    Single Settlements Resolving Multiple Dates of Loss

A new policy was introduced to instruct RREs how to report single settlements with one RRE involving multiple dates of loss:
“Where there are multiple incidents (multiple dates of incident) being resolved with one TPOC, the RRE shall report the earliest date of incident and include all diagnosis codes being settled for all dates of incident. This applies regardless of the timing of the subsequent dates of incident, the nature of the injuries, or any allocation made to each date of incident in the settlement documents. This ensures that all medicals that were released by the settlement are accurately recovered while still affording the beneficiary a dispute and administrative appeal process if any claims are erroneously identified.”

So, what does this mean? Let’s take a California workers’ compensation claim settling with a cumulative trauma claim going back to 2010, two soft tissue injuries from 2014 and 2016, and a major accident that occurred in 2023. While the 2023 accident is the driving force in the settlement and is likely the dominant date of loss, CMS’ new policy is that for TPOC reporting purposes the only date to report is 2010 (the earliest date of loss) and the 2010 dates of loss should include all injuries and amounts being released in the global settlement, regardless of when the injuries occurred or how the settlement allocates dollars across each settlement.

This is a complete reversal of the last fifteen years of guidance from CMS on this topic. Previously, guidance on this topic was that each date of loss should be independently reported, and if necessary multiple records could be reported with corresponding TPOC amounts. That approach prevented recovery errors and avoided misapplied conditional payments. CMS is now saying that the only TPOC date that matters is the first one and that it will still afford “the beneficiary a dispute and administrative appeal process if any [conditional payment] claims are erroneously identified.” 

This new guidance comes in the wake of the WCMSA reporting challenges, where RREs inquired how to report an MSA in the above scenario. CMS solves that problem requiring RREs to simply use the earliest date of loss to report the entire settlement. Nonetheless, the agency acknowledges that beneficiaries could face improper / unwanted recovery. This leaves us contemplating whether we will be monitoring the downstream impact of this change, wondering if another T-rex just escaped.

2)    Multiple Settlements Involving the Same Individual

CMS clarified its guidance to more directly explain that RREs should only report their portion of a settlement and not the aggregate amount. “If there will be multiple TPOCs submitted for the same individual, for the same incident, but reported by different RREs, the records shall reflect each RRE’s unique TPOC amount and not the aggregate TPOC the beneficiary will be receiving. If more than one RRE has assumed responsibility for ongoing medicals, Medicare would be secondary to each such entity.”

The prior direction from CMS was that each RRE “must report appropriately” and “if there will be multiple records submitted for the same individual but coming from different RREs they will be cumulative rather than duplicative.” This language is rather indirect and led, in some cases, to misinterpretation among RREs as to what is the correct TPOC amount to report. The new guidance more explicitly notifies RREs that they are to report only their share. The only exception for this would be joint and several liability settlements. 

We have received questions about joint and several liability settlements. While joint and several liability judgments are common, joint and several liability settlements are not. Unless there is a jurisdictional presumption in favor of a joint and several liability settlements, or the settlement specifically calls out that it is in fact joint and several, our guidance is to report “each RRE’s unique TPOC amount and not the aggregate TPOC the beneficiary will be receiving.”

3)    Medicare Set Asides – New Reporting Rules

CMS also released brand new guidance on Medicare Set Asides. “As it relates to multiple dates of incident, an MSA, if applicable, shall be reported under the same guidance as above. That is, the earliest date of incident, if only one TPOC is made. If multiple TPOCs are submitted, but only one MSA is reported, the MSA shall be reported on the first TPOC only. Where there are multiple defendants (RREs) reporting in this scenario, the same guidance applies to MSAs as it does to TPOCs.”

This new policy announcement means that in a multiple DOL settlement with one RRE, the RRE should only be reporting the WCMSA amounts on the earliest injury date. Again, under the new policy, no TPOC would be reported for the subsequent dates of loss. Where ORM had been reported in those subsequent dates of loss, the RRE would simply terminate ORM and place all TPOC reporting (as well as any WCMSA) on the first date of loss. CMS’ wording leaves some ambiguity, particularly around sharing responsibility across multiple defendants. This language implies that each responsible for reporting their own MSA – but that is rarely how a claim actually settles. We recommend that CMS address this in the next User Guide update.

Additional questions worth asking:

• What insurance types are covered? The guidance applies to all insurance types. We do not anticipate much impact on liability, but we do anticipate a significant impact on workers’ compensation claims where it is common to settle several dates of loss in one agreement.
• What’s the real-world application of the guidance regarding “multiple settlements involving the same individual”? At the end of the day, not much. CMS more directly explained that each RRE should report the “RRE’s unique TPOC amount and not the aggregate.” While this may be slightly nitpicky, labeling this section as “multiple settlements involving the same individual” is confusing. The new language very clearly explains that these multiple TPOCs would be “for the same incident.” We will advise our clients to follow this language where they are contributing to a global resolution, and to report their share only (barring a joint and several settlements). 
• Any word on the practical impact of WCMSA reporting or the postponed Town Hall call? Nothing as of yet. Industry stakeholders continue to await CMS’ rescheduled Town Hall. Several WCMSAs are currently held up in review due to programming changes made by CMS in response to MSA reporting data. Those WCMSAs remain in limbo as we continue to await further guidance from CMS as to whether (if ever) those claims will be reviewed.
• What is the practical impact of these changes? These changes will require updated training and (in some cases) updated claims system programming. Particularly in workers’ compensation, ensuring that clear guidance is provided to all parties - claims examiners, counsel, judges, and claimants - that multiple dates of loss will be reported as a settlement only on the earliest date of loss. Counsel and judges will need to take particular care to educate claimants on the need to aggressively dispute any conditional payments post-settlement.  Furthermore, to the extent that the employer agrees to handle post-settlement conditional payments, they too should be aware of these important changes and the implications for inflated conditional payment demands.
• What else is in the latest User Guide? This new User Guide provides important policy updates in Chapter 3 surrounding TPOC (aka settlement) reporting for multiple defendant and multiple date of loss scenarios. Technical changes include the addition of certain reason codes to the unsolicited response file and a new requirement (effective April 2026) that the reporting agent include their EIN. 

Should you have any questions please contact your local ECS regional compliance consultant, ECS MIR Service Support, or the ECS Compliance Team at mspcompliance@examworkscompliance.com.