Earlier this month CMS released an updated NGHP Section 111 User Guide. Version 8.3 of the guide is notable mostly for what didn’t change, considering that version 8.2 had only been released in November.
What’s New?
There are a few substantive changes, none of which are particularly earth-shattering.
Chapter 1 Changes
The only change in chapter 1 is a clarification that CMS will return the beneficiary’s most-recent Medicare ID number when a positive query is returned.
Chapter 2 Changes
Chapter 2 includes the same changes as in Chapter 1.
Chapter 3 Changes
CMS elected to maintain the $750 minimum reporting threshold for TPOC events in liability, workers’ compensation, and no fault settlements. The $750 threshold has been in place for years and it’s not anticipated that CMS will adjust this threshold any time soon.
Chapter 4 Changes
Chapter 4 includes further clarification that the most recent Medicare ID will be provided.
Chapter 5 Changes
Chapter 5 added language to the claim response file to explain that “If no [Medicare ID] match is found, the position will be filled with spaces.”
What wasn’t included?
Version 8.2 of the User Guide outlined policy changes (or clarifications, depending on your point of view) regarding multiple date of loss settlements, multiple defendant settlements, and the new mandatory MSA reporting process. Given all of those changes, it’s perhaps not surprising that CMS reserved only minor updates for this version.
Another change not found in this version? CMS’ announcement last week during its Civil Money Penalty Webinar that workers’ compensation claims will not be eligible for CMPs until July 2026. CMS made this announcement to account for the mandatory MSA reporting changes that were introduced for claims settling on and after April 4, 2025.
Food for thought: Other changes we’d like CMS to consider
Mandatory MSA reporting dominated the headlines in 2025, complicating reporting for workers’ compensation claims payers and creating a number of technical and practical challenges for the industry. At the same time, CMS will begin sharing prescription NDC numbers on submitted MSAs with Part D insurers allowing them to deny at the point of sale. CMS’ focus on WCMSAs may obscure the true obstacles to beneficiary coverage and coordination of benefits efficiency. Here are some ideas for ways that CMS could make this program easier on all parties:
Make ORM termination easier. Current guidance allows ORM to be terminated when no medicals have been paid for five years and less than $25,000 in total medical has been paid (in addition to terminating upon denial, terminating at settlement, etc.). If CMS were to moderate these requirements more non-consequential claims could be terminated, preventing unnecessary and wasteful payment denials from providers and Medicare contractors.
Make WCMSA data exchange transparent. Despite the industry’s requests, CMS has never really published the behind-the-scenes data flow on mandatory MSA reporting. We’d like CMS to explain the cause and effect of mandatory MSA reporting on submitted MSAs, including the downstream impact to beneficiaries, claims payers, and professional administration companies.
Still waiting on the WCMSA webinar. CMS had planned a webinar on October 1, 2025, only to have the webinar scuttled due to the government shutdown. The updated webinar date has not yet been provided but the industry continues to await additional answers and context from CMS. This webinar could be particularly helpful for claimant attorneys and judges who are often confused about what the requirements mean. In October we summarized what we’d like to hear from CMS in October and many of those requests remain unchanged.
ECS is available to help assess the effect of these changes on your reporting program. 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.