Version 6.2 of NGHP MMSEA Section 111 User Guide Released

CMS, Mandatory Insurer Reporting, Medicare Set-Aside Blog on January 22, 2021
Posted by Shannon Flynn

Recently, the Centers for Medicare & Medicaid Services (CMS) released Version 6.2 of the Non-Group Health Plan (NGHP) MMSEA Section 111 User Guide, a key resource for addressing Section 111 reporting requirements as mandated by Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA).

To help you stay up to date on important changes, a breakdown of the four updates included in Version 6.2 (along with our summary/commentary) is provided below.

  1. Chapter II – Summary of Version 6.2 (Registration Procedures) Updates (1-1)

    As part of CMS’ commitment to the modernization of the Coordination of Benefits & Recovery (COB&R) operating environment, changes are being implemented to move certain electronic file transfer data exchanges to the CMS Enterprise File Transfer (EFT) protocol. As part of this change, the exchange of data with the COB&R program via Connect:Direct to GHINY SNODE will be discontinued. The final cutover is targeted to occur in April 2021. File naming conventions and other references have been updated in this guide. Contact your EDI Representative for details (Section 4.2.4).

    Connect: Direct is one of the four methods of data transmission that RREs may utilize to submit query/reporting data to CMS. Connect: Direct is an electronic file submission method that connects to the CMS Extranet Network and CMS’ private CMSNet network. This method is suggested for RREs with very large volume (files with more than 24,000 records transmitted at once). If this applies to your organization, we recommend contacting your EDI representative for details and next steps.

  2. Chapter III– Summary of Version 6.2 (Policy Guidance) Updates (1-1)

    As of January 1, 2021, the threshold for physical trauma-based liability insurance settlements will remain at $750. CMS will maintain the $750 threshold for no-fault insurance and workers’ compensation settlements, where the no-fault insurer or workers’ compensation entity does not otherwise have ongoing responsibly for medicals (Sections 6.4.2, 6.4.3, and 6.4.4).

    This is further confirmation that settlement thresholds for reporting are not changing for 2021.

  3. Chapter IV – Summary of Version 6.2 (Technical Information) Updates (1-1)

    To support previous system changes, Policy Number (Field 54) has been added as a key field. If this field changes, RREs must submit a delete Claim Input File record that matches the previously accepted add record, followed by a new add record with the changed information (i.e., delete/add process) (Sections 6.1.2, 6.6.1, 6.6.2, and 6.6.4).

    Policy Number (Field 54) is now a key field, which requires previously accepted records to be deleted and then resubmitted as a new add record with the changed information. Medicare stores information on claims submitted previously using certain fields that identify the beneficiary as well as key fields: CMS DOI (Field 12), Plan Insurance Type (Field 51), Policy Number (Field 54), and ORM Indicator (Field 78). The BCRC must be able to match the beneficiary information and key fields that are submitted. For example, an insurance company took over claims from a previous insurance company and the policy number changed. For the next Claim Input File, the RRE must first delete the previously reported record and then add a record with the new insurance carrier’s name and policy number.

  4. Chapter V – Summary of Version 6.2 (Appendices) Updates (1-1)

    To address situations where Responsible Report Entities (RREs) can identify future ORM termination dates based on terms of the insurance contact, Responsible Reporting Entities (RREs) can now enter a future Ongoing Responsibility for Medicals (ORM) Termination Date (Field 79) up to 75 years from the current date (Appendix A and Appendix F).

    RREs can now enter a future ORM Termination Date up to 75 years from the current date for cases with future ORM termination dates based on insurance contracts.

    Retraction – In Version 6.1, we announced that several input errors will become “soft” errors starting April 5, 2021. However, CP03 will not become a soft edit. The Office Code/Site ID (Field 53), which triggers CP03, is used to identify correspondence addresses, and if incorrect, could result in mail being sent to the wrong place. Therefore, this error will continue to reject the record (Appendix F).

    Retraction: Error CP03 (Office Code/Site ID) will no longer be considered a soft error because it may result in mail being sent to the wrong place. The Office Code/Site ID is an RRE-defined number that can be used when the RRE has only one TIN, but wishes to associate claims (and the corresponding mailing address for the RRE) to different offices or sites. The Office Code/Site ID can also be used when assigning a Recovery Agent.

You can download the various chapters of Version 6.2 of the NGHP MMSEA Section 111 User Guide at cms.gov.