CMS Releases Version 6.3 of NGHP MMSEA Section 111 User Guide

CMS, Mandatory Insurer Reporting, Medicare Set-Aside Blog, MSP News on April 13, 2021
Posted by Shannon Flynn

by Frank Fairchok, Vice President of Medicare Reporting Services and AnnaMarie Sorrento, Programs and Projects Manager

Last week, the Centers for Medicare & Medicaid Services (CMS) released Version 6.3 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).

As the Centers for Medicare & Medicaid Services (CMS) has indicated on prior Section 111 NGHP Town Hall teleconferences, they will continue to review reporting requirements and will post any applicable updates in the form of revisions to Alerts and the user guide as necessary.

To help keep you up to date on key changes, a breakdown of the updates included in Version 6.3, as well as our analysis, is provided below.

Chapter III– Summary of Version 6.3 (Policy Guidance) Updates

The updates listed below have been made to the Policy Guidance chapter of version 6.3 of the NGHP User Guide.

To align with the terms and conditions regarding the acceptance of Ongoing Responsibility for Medicals (ORM) as described in Section 6.4, the language around periodic payments or one-time settlements to compensate for lost wages has been clarified (Section 6.5.1). 

Change to Section 6.5.1, page 6-22
In version 6.2 was “For example, if an RRE is making period “indemnity-only” payments or a one-time “indemnity-only” settlement to the injured party to compensate for lost wages related to the underlying workers’ compensation or no-fault claim, the RRE has implicitly, if not explicitly, assumed ORM. Therefore the RRE shall report the ORM. The periodic payments or one-time settlement to compensate for lost wages are not reported as TPOCs.”

In version 6.3 was revised to “The periodic payments or one-time settlement to compensate for lost wages are not reported as TPOCs, but may be included to compute the total TPOC amount. (Note: TPOC compensation is outlined in Section 6.4.)”

Chapter IV – Summary of Version 6.3 (Technical Information) Updates

The updates listed below have been made to the Technical Information Chapter Version 6.3 of the NGHP User Guide.

Several Section 111 input record errors that would cause a record to reject will no longer cause the input records to be rejected. RREs, however, will continue to receive the errors on their response files, and they should correct and resubmit on their next quarterly file submission. The errors include: CC05, CC11, CC12, CC13, CC25, CC31, CC32, CC33, CC45, CC51, CC52, CC53, CC65, CC71, CC72, CC73, CI02, CI03, CI25, CP06, CP07, CP08, CP09, CP10, CP13 (new), CR11, CR12, CR13, CR14, CR31, CR32, CR33, CR 34, CR51, CR52, CR53, CR54, CR71, CR72, CR73, CR 74, CR91, CR92, CR93, CR94, and TN30 (Section 7.1 and NGHP Chapter V).

Change to Section 7.1, Page 7-6
Paragraph added as follows: “Several Section 111 input record errors that would cause a record to reject will no longer cause the input records to be rejected. RREs, however, will continue to receive the errors on their response files, and they should correct and resubmit on their next quarterly file submission (see NGHP Chapter V).”

Claim Input File Detail Records, and Direct Data Entry (DDE) records, submitted prior to the effective date of the injured party’s entitlement to Medicare will be rejected and returned with a Disposition Code ‘03’ instead of an SP31 error (Section 7.2).

Change to Section 7.2, Page 7-6
Paragraph was deleted for SP31 error.

Chapter V – Summary of Version 6.3 (Appendices) Updates

The updates listed below have been made to the Appendices Chapter Version 6.3 of the NGHP User Guide.

Several Section 111 input record errors that would cause a record to reject will no longer cause the input records to be rejected. RREs, however, will continue to receive the errors on their response files, and they should correct and resubmit on their next quarterly file submission. The errors include: CC05, CC11, CC12, CC13, CC25, CC31, CC32, CC33, CC45, CC51, CC52, CC53, CC65, CC71, CC72, CC73, CI02, CI03, CI25, CP06, CP07, CP08, CP09, CP10, CP13 (new), CR11, CR12, CR13, CR14, CR31, CR32, CR33, CR 34, CR51, CR52, CR53, CR54, CR71, CR72, CR73, CR 74, CR91, CR92, CR93, CR94, and TN30 (Appendix F).

Change to Section 7.1, Page 7-6
Paragraph added as follows: “Several Section 111 input record errors that would cause a record to reject will no longer cause the input records to be rejected. RREs, however, will continue to receive the errors on their response files, and they should correct and resubmit on their next quarterly file submission (see NGHP Chapter V).”

A new edit has been added and applied to NGHP Claim Input File Detail Record files when users submit a no-fault insurance claim where the policy limit is less than $1000.00. The input files will be accepted but a new CP13 error will be returned on the response files to notify users to confirm the dollar amount submitted. Direct Data Entry (DDE) submitters will see a message on the Insurance Information page but will be able to proceed with data entry without correcting (Appendix F).

Change to Appendix F, Page F-40
The CP13 error was added to the table on page F-40. The text “Effective April 5, 2021” was deleted in Version 6.3.

Claim Input File Detail Records, and Direct Data Entry (DDE) records, submitted prior to the effective date of the injured party’s entitlement to Medicare will be rejected and returned with a Disposition Code ‘03’ instead of an SP31 error.

SP31 Error was deleted from the table in Version 6.3.

A clarification has been added to the No-Fault Insurance Limit field (61), and to the CP11 error code, to indicate that you cannot add zeros as valid values if the Plan Insurance Type is “D” (No-Fault Insurance) for MSP submissions (Appendix A, Appendix F).

Version 6.3, page A-16
Field 61: Added text “All zeroes is not a valid value if the Plan Insurance Type is D.”

Version 6.3, Page F-39
CP11 Error: Added text “Was zero-filled when Field 51 = D”

Our Analysis

While this revised User Guide appears to have many changes, several were previously announced in versions 6.1 and 6.2. CMS may have used this update as an opportunity to refine these changes, as the effective date for some items occurred on the date of this latest revision. CMS has also indicated, via the Town Hall call held on April 1, 2021, that a User Guide update can be expected in June 2021.

However, there is one update, to Section 6.5.1, page 6-22, that is worthy of a deeper look. The modified wording around periodic payments for lost wages states “The periodic payments or one-time settlement to compensate for lost wages are not reported as TPOCs, but may be included to compute the total TPOC amount. (Note: TPOC compensation is outlined in Section 6.4.)”

It seems clear that CMS does not consider these payments to be individual TPOCs, but an RRE may use them to determine if they have reached a TPOC threshold amount. To place this in proper context, we need to bring in other pertinent TPOC criteria (from Section 6.4 of Chapter IV) that states:

“The TPOC Amount refers to the dollar amount of a settlement, judgment, award, or other payment in addition to or apart from ORM.

So, if the RRE has properly assumed and reported ORM, and the ORM status is not impacted by these payments, they do not need to be reported. However, if a TPOC occurs that changes the ORM status for some (or all) of the claimed injuries, CMS will allow the value of these payments to be included in the TPOC calculation and determine if threshold has been attained. This is consistent with the guidance in the second paragraph in Section 6.4 of Chapter IV which states:

“The computation of the TPOC amount includes, but is not limited to, all Medicare covered and non-covered medical expenses related to the claim(s), indemnity (lost wages, property damages, etc.), attorney fees, set-aside amount (if applicable), payout totals for all annuities rather than cost or present values, settlement advances, lien payments (including repayment of Medicare conditional payments), and amounts forgiven by the carrier/insurer.”

Essentially, CMS is satisfied with payments being made to a claimant if the RRE retains ORM responsibility, as it can recover any conditional payments through the CRC’s processes. Once the ORM recovery is in jeopardy due to a TPOC event that could terminate ORM however, the focus for CMS turns to understanding the value within the TPOC.    

You can download the various chapters of Version 6.3 of the NGHP MMSEA Section 111 User Guide at cms.gov.