CMS Releases Updated NGHP User Guide, Version 5.3

CMS, Medicare Set-Aside Blog on December 22, 2017 | Posted by Jean S. Goldstein, JD

CMS updated their Non-Group Health Plan (NGHP) User Guide, and released version 5.3.  The updated guide can be found here.


The update to the guide essentially addresses CMS’ long planned transition, as previously reported, from use of Social Security Number (SSN) based Medicare identifiers to use of Medicare Beneficiary Identifiers (MBIs).  CMS provided an exemption for all Medicare Secondary Payer processes from exclusive use of the MBI; such that reporting should not be effected by this transition.  For Section 111 mandatory insurer reporting NGHPs are still able to report using the Health Insurance Claim Number (HICN), social security number, or MBI.  The fields previously labeled as “HICN” are simply now labeled as “Medicare ID” and this field can accept either the MBI or an HICN.  The guide also indicates the most current issued Medicare ID will be returned in the response file in the newly created Medicare ID field; meaning that “…if an RRE submits information with a HICN and the Medicare beneficiary has received their MBI, the MBI will be returned. Otherwise, the most current HICN will be returned.”  Either the HICN or MBI can still be utilized on all reporting and searches for claims.  Most importantly, SSNs can be still be used to query via the Health Eligibility Wrapper (HEW) 270/271 query process.  Upon querying the system, whichever is the most current Medicare identifier, either HICN or MBI will be returned in the “Medicare ID” field. With respect to correspondence received from either the Benefits Coordination and Recovery Center (BCRC) and Commercial Repayment Center (CRC) these entities will use the Medicare identifier that was provided when the MSP record was being created.  Lastly, the guide also added in an escalation process for addressing issues.


We will keep you updated on any additional CMS changes or CMS issued guidance.