On June 5th the Centers for Medicare & Medicaid Services (CMS) released an updated Section 111 Non Group Health Plan (NGHP) User Guide. Version 7.2 of the User Guide provides key updates regarding what triggers ongoing responsibility for medicals (ORM), changes to the use of the NOINJ code in liability reporting, and the new unsolicited response file. These changes and clarifications are welcome, and we summarize them here.
“NOINJ” Policy Change
For over a decade, CMS has required Section 111 reporting in any case where medicals are “claimed or released” or the settlement “has the effect of releasing medicals.” Under this policy, in cases involving Medicare beneficiaries where a broad, general release was obtained – including claims, not yet raised, for medical damages – then parties were to report the settlement with the ICD code listing “NOINJ” for “no injury.” Under this policy, a number of emotional distress, employment law, and other claims that involved no direct physical injury have been reported to Medicare.
Yesterday, CMS made “NOINJ” reporting, optional. The updated guidance now reads:
“Note: In cases where reporting of a liability record only meets the criteria for reporting a ‘NOINJ’ diagnosis code in Field 18, the reporting of the record is no longer required. However, it is optional for the RRE to report the record with the ‘NOINJ’ diagnosis code following previously existing rules in the User Guide.”
Impact: Significant. With this note, CMS has made resolution of tens of thousands of claims per year much easier. RREs are no longer required to identify Medicare beneficiaries whose settlements involve no injury, but whose releases effectively release non-existent medical claims. By focusing on actual injury claims, claims professionals and lawyers can quickly and expeditiously resolve these claims without have to check the box on this pointless endeavor. CMS should be congratulated for this policy change and we thank them for making this adjustment.
ORM Trigger Clarification
CMS updated guidance for what behavior triggers ORM reporting. The new language is:
“The trigger for reporting ORM is the assumption of ORM by the [responsible reporting entity], which is when the RRE as made a determination to assume responsibility for ORM and when the beneficiary receives medical treatment related to the injury or illness.” (new language in bold)
The new language clarifies that an injured party must actually receive medical treatment in order for ORM reporting to be required. This language will please some RREs – particularly those who offer no fault coverages – that have reported ORM on claims where they are aware that an accident occurred but where medical treatment may never have been received. These information-only claims, if they are reported, can lead to headaches when a beneficiary struggles with coverage confusion between the provider and no fault carrier.
With these changes, the beneficiary must “receive medical treatment,” which is in contrast to situations where a carrier receives a claim report with nothing more than a general injury complaints, but with no treatment sought by the so-called injured party. While not all RREs reported such claims that as ORM, a number of no-fault carriers reported these claims due to the Medicare’s guidance that “medical payments do not actually have to be paid, nor does a claim need to be submitted, for ORM to be required.” While Medicare has retained the language that medical payments do not have to be paid, the beneficiary must in fact receive medical treatment.
Impact: Significant for those that chose to report claims without medical treatment. This clarification should resolve issues that arise whenever an RRE reports a minor accident where no medical treatment is sought, particularly in no fault claims. It is worth noting that minor medical-only workers’ compensation claims that do not exceed $750 in medical are generally not required to be reported. No such exclusion exists in no fault. Rather than apply a dollar threshold, CMS is clarifying that the beneficiary must have “received” medical treatment related to the incident. We welcome this clarification.
ORM Termination Date When Doctor’s Note is Obtained
CMS offered guidance on calculating the ORM termination date when a doctor’s note is used as the foundation to terminate ORM. The new guidance is:
“Where an RRE is relying upon a physician’s statement to terminate ORM, the ORM termination date to be submitted should be determined as follows:
- Where the physician’s statement specifies a date as to when no further treatment was required, that date should be the reported ORM termination date;
- Where the physician’s statement does not specify a date when no further treatment was required, the date of the statement should be the reported ORM termination date;
- Where the physician’s statement does not specify a date when no further treatment was required, nor is the statement dated, the last date of the related treatment should be used as the ORM termination date.”
Impact: Minor. Although ECS does not receive many questions about this topic, we welcome this very specific guidance.
Unsolicited Response File
CMS also adjusted the Unsolicited Response File guidance. Later today CMS will hold a Town Hall Call to provide an overview of the Unsolicited Response File. ECS will provide further updates on the Unsolicited Response File following the Town Hall Call.
As always, should you have any questions about ECS’ Section 111 reporting services or how these policy changes impact your claims, please contact Marty Cassavoy at 781-517-8085 or email@example.com.