CMS releases new NGHP Section 111 User Guide (Version 6.5)

By Mark Popolizio, J.D., Jeremy Farquhar

October 8, 2021 / 9 min read

The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 NGHP User Guide (Version 6.5, October 4, 2021) regarding non-group health plans (liability, no-fault and workers’ compensation). This updated guide replaces Version 6.4 (June 11, 2021).

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As usual, CMS lists the new updates in the beginning of each User Guide chapter in a “Summary” page. Reviewing these pages indicates that updates were made to Chapter II (Registration Procedures), Chapter III (Policy Guidance); Chapter IV (Technical Guidance); and Chapter V (Appendices).

In general, the new User Guide contains various changes to different Section 111 compliance areas, including the Query Response File, CMS’s DOI prior to December 5, 1980, MSP record updates involving dates three months in the future, and other updates.

A general overview of these and other updates made by CMS is provided as follows:

Query Response File changes

As part of the Chapter II updates, CMS incorporates into the Guide the information it will be providing RREs as part of its PAID Act implementation plans as previously announced by the agency. Specifically, CMS notes that “[t]o support the PAID Act, RREs will receive Part C (Medicare Advantage Plan) and Part D (Medicare prescription drug coverage) enrollment information for the past 3 years, as well as the most recent Part A and Part B entitlement dates, on the Query Response File (Chapter 3).”[1]

As part of the Chapter IV updates, CMS advises that starting December 11, 2021 the Query Response File will be updated to include: “Contract Number, Contract Name, Plan Number, Coordination of Benefits (COB) Address, and Entitlement Dates for the last three years (up to 12 instances) of Part C and Part D coverage. The updates will also include the most recent Part A and Part B entitlement dates. The HIPAA Eligibility Wrapper Software (HEW) software will also be modified to extract the additional fields from the response file (see Chapter V, HEW Query Response File Record – Version 4.0.0 - Appendix K).”[2]

CMS date of injury (DOI) prior to 12/5/80

CMS has made updates, it terms as “clarifications,” to Chapter III involving situations when the DOI is prior to December 5, 1980. Specifically, CMS has added language to indicate that reporting of a claim involving exposure to an environmental hazard or continued ingestion of a particular substance would be inappropriate in scenarios where that exposure or ingestion had ended prior to 12/5/80.

This updated language was added to Section 6.5.1 and reads as follows

“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.” (Chapter III, Section 6.5.1, p. 6-23).
“In these situations, it would be inappropriate to submit an MMSEA Section 111 report.” (Chapter III, Section 6.5.1, p. 6-24).

CMS will now accept records with MSP dates up to 3 months in the future

As part of CMS’s summary of changes related to Chapters IV and V, CMS indicates that “these records [records with MSP dates up to 3 months in the future] will no longer be held and submitted when the beneficiary’s eligibility comes into effect.”[3]

Regarding this update, the authors note CMS’s use of language indicating that these records will no longer be “held” to be interesting since, historically, records related to beneficiaries with future Medicare entitlement dates have not previously been “held” by CMS (or RREs, for that matter). In this regard, typically RREs would submit records once a positive Medicare eligibility response had been received via the monthly query process. Previously, in situations where the submission may have occurred prior to the beneficiary’s Medicare entitlement date, CMS would return an ‘03’ disposition and, in situations involving continuing ORM, the RRE would be required to resubmit the coverage on their subsequent quarterly file. For more detailed information regarding the technical impact of this change, please see our recently published article which outlines CMS’s recently announced policy updates regarding their acceptance of MSP records involving future Medicare effective dates.

Further, it is noted that CMS’s update to Chapter IV includes a newly added statement within Chapter 7 on page 7-1 which reads, “Records for an injured party who could not be identified as a Medicare beneficiary (on or up to 3 months from the submission date) will be returned with an error.” The authors find this language interesting in that, while it seems this language was added to highlight the fact that CMS will now accept coverage record submissions for beneficiaries with entitlement dates as much as 3 months into the future, the reference to the receipt of an “error” is questionable and confusing. In this regard, it is noted that CMS’s current process does not return an error when no match is found to a beneficiary on a coverage record submission. Rather, a ‘51’ disposition would be returned in order to indicate that the individual for whom the coverage is being reported was not successfully identified as a Medicare beneficiary.

On another front, within CMS’s summary of the Chapter V updates, CMS indicates that updates were applied to Appendix C (Claim Response File Layout).[4] However, per the authors’ review, no changes were identified in relation to future MSP dates within Appendix C. Based on the nature of this change, it would appear to the authors that updates to the Claim Response File Layout may not be entirely necessary.

Beneficiary lookup function has been expanded to DDE reporters

As part of its Chapter IV updates, CMS notes that “[t]o support the PAID Act, the beneficiary lookup function has been extended to DDE reporters (Chapter 3, Sections 8.5 and 10.5).”[5]

Miscellaneous Updates

In addition to the above outlined changes, CMS has made other various updates and changes. These changes, along with noted author comments, are as follows:

TN30 error – TIN Reference Response File

CMS notes that “because the TN30 error no longer causes input records to be rejected, descriptions of the TIN Reference Response File process have been updated (Section 6.3.3).”[6] Authors’ note: This update appears to be in reference to the removal of a bullet point from Chapter IV, Section 6.3.3, page 6-20 which previously read, “Spaces in the TIN Error 1-10 (Fields 23 - 32)” under the “If a TIN Reference File Detail Record passes the TIN and TIN address validation, it will be accepted and a TIN Reference Response File Detail Record returned with” header. As CMS has noted, the TN30 error will no longer cause a TIN detail record to be rejected. However, this error will still be returned in instances where the Recovery Agent Zip +4 (field 22) does not contain 4 numeric digits, all zeros or all spaces. This ties back to changes that took effect on April 5, 2021 in relation to certain error codes which will no longer cause an RRE’s record submission to be rejected. For a more detailed overview of this change, please refer to our prior article. As a result, it may now be possible for an accepted TIN detail record to receive this TN30 error and hence the removal of the aforementioned language to coincide with this process change.

Excluded ICD-10 code

CMS notes that “[t]he ICD-10 diagnosis codes for Excluded All Types and No-Fault Plan Insurance Type D have been updated for FY 2022 (Appendix I and Appendix J).” [7] Authors’ Note: In addition to the updates to the excluded code listings contained within Chapter V, CMS has also published updated ICD code listings via the Reference Materials file menu on their Section 111 COB Secure Website (https://www.cob.cms.hhs.gov/Section111/). These updated code listings take effect as of January 2022 and include both Excel and text versions of the Valid ICD-9, Valid ICD-10, Excluded ICD-9 and Excluded ICD-10 Code Listings.

Applied error codes – TIN error codes

CMS states that “[b]ecause several input errors no longer cause the input records to be rejected, the descriptions for Applied Error Codes and TIN Error Codes have been updated (Appendix C and D).”[8] Authors’ Note: This update simply removes a single sentence which had previously been uniformly displayed in each Applied Error Code Description field within the Claim Response File Layout (Appendix C) and the TIN Reference Response File Layout (Appendix D). The sentence which was removed previously read, “Provided only if disposition code denotes error.” As also referenced above, as of part of CMS’s April 5, 2021 updates, CMS advised that it would no longer reject coverage records in connection with a variety of error codes as referenced in our prior article. These error codes are still returned on an RRE’s Claim Response File but, unless returned in conjunction with another error which would still result in a rejection, will now be coupled with an accepted ‘01’ or ‘02’ disposition code as opposed to an ‘SP’ disposition which would indicate rejection due to errors. Hence CMS’ removal of the aforementioned sentence.

HEW Translation table – HEW Query Input File layout

CMS notes that the HEW Translation table (Table K-1) has been updated for clarification (Appendix K) and the HEW Query Input file layout has been corrected (Appendix E).[9] Authors’ Note: Upon careful review, the authors have been unable to identify any corrections or updates applied to the HEW Query Input File layout (Appendix E) via comparison with version 6.4 of the NGHP User Guide.

Questions?

Please contact the authors if you have any questions regarding CMS’s updates or other issues related to Section 111 reporting.

[1] CMS’s Section 111 NGHP User Guide, Chapter II (Version 6.5, October 4, 2021), Chapter 1, p. 1-1.

[2] CMS’s Section 111 NGHP User Guide, Chapter IV (Version 6.5, October 4, 2021), Chapter 1, p. 1-1. See also, CMS’s Section 111 NGHP User Guide, Chapter V (Version 6.5, October 4, 2021), Chapter 1, p. 1-1.

[3] CMS’s Section 111 NGHP User Guide, Chapter IV (Version 6.5, October 4, 2021), Chapter 1, p. 1-1 and Chapter V, Chapter 1, p. 1-1.

[4] CMS’s Section 111 NGHP User Guide, Chapter V (Version 6.5, October 4, 2021), Chapter 1, p. 1-1.

[5] CMS’s Section 111 NGHP User Guide, Chapter IV (Version 6.5, October 4, 2021), Chapter 1, p. 1-1.

[6] CMS’s Section 111 NGHP User Guide, Chapter IV (Version 6.5, October 4, 2021), Chapter 1, p. 1-1.

[7] CMS’s Section 111 NGHP User Guide, Chapter V (Version 6.5, October 4, 2021), Chapter 1, p. 1-1.

[8] CMS’s Section 111 NGHP User Guide, Chapter V (Version 6.5, October 4, 2021), Chapter 1, p. 1-1.

[9] CMS’s Section 111 NGHP User Guide, Chapter V (Version 6.5, October 4, 2021), Chapter 1, p. 1-1.