CMS Releases Updated NGHP User Guide

CMS, Mandatory Insurer Reporting, Medicare Set-Aside Blog, MSP News on January 9, 2017
Posted by Jean S. Goldstein, JD, CMSP

CMS updated their Non-Group Health Plan (NGHP) User Guide, and released version 5.2.  The updated guide can be found here.

The only update to the guide is the change in thresholds for reporting certain cases with total payment obligation to the claimant (TPOC), as indicated in CMS’ recently issued alerts and as previously discussed here on our blog.  Specifically, if there is no ongoing responsibility for medicals (ORM) then:

  • TPOC for liability cases has changed from $1000 to $750 for dates of 1/1/2017 and after; and
  • TPOC for no-fault cases and workers’ compensation cases now has a threshold for reporting of $750 for dates of 10/1/2016 and after.

TPOC amounts that exceed these thresholds must be reported, and amounts less than the specified threshold may be reported. The CJ07 error code will continue to be returned for cases where there is no ongoing responsibility for medical indicated, and the total TPOC is $0.   As we previously stated, CMS’ threshold changes mean that a Required Reporting Entity is not required to report if the total TPOC does not fall within one of the above; nor will CMS seek recovery on theses cases.

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