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CMS Publishes NGHP Section 111 User Guide Version 7.2

June 20, 2023
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User Guide spelled out in wooden blocks

by F. Fairchok

The Centers for Medicare & Medicaid Services (CMS) published an update to the Non-Group Health Plan (NGHP) Section 111 Reporting User Guide on June 5, 2023. This updated User Guide, Version 7.2, contains changes relating to ORM, ORM Termination, and the Unsolicited Response File, as well as other important updates.

Ongoing Responsibility for Medicals (ORM) Reporting

This update to the User Guide modifies policy around the assumption of ORM by the Responsible Reporting Entity (RRE). The guide has been modified to add criteria for the beneficiary receiving medical treatment related to the injury or illness. There is also a clarification added in Chapter III, Section 6.3 that the ORM effective date is the same as the CMS Date of Injury (DOI) as follows (note: bold text indicates updated/revised language):

The trigger for reporting ORM is the assumption of ORM by the RRE, which is when the RRE has made a determination to assume responsibility for ORM and when the beneficiary receives medical treatment related to the injury or illness. Medical payments do not actually have to be paid, nor does a claim need to be submitted, for ORM reporting to be required. The effective date for ORM is the DOI, regardless of when the beneficiary receives the first medical treatment or when ORM is reported.

ORM Termination

CMS has clarified that when an RRE relies upon a physician’s statement to terminate ORM, the ORM termination date to be submitted should be determined as follows (Chapter III, Section 6.3.2):

    • Where the physician’s statement specifies a date as to when no further treatment was required, that date should be the reported ORM termination date;
    • Where the physician’s statement does not specify a date when no further treatment was required, the date of the statement should be the reported ORM termination date;
    • Where the physician’s statement does not specify a date when no further treatment was required, nor is the statement dated, the last date of the related treatment should be used as the ORM termination date.

Unsolicited Response File Changes

Once again, CMS made several changes to the Unsolicited Response File structure and process. While those changes are documented here, we expect there will be additional updates in version 7.3 of the NGHP User Guide (most likely coming sometime later this month or in early July).

In Chapter IV, Section 7.5, CMS added the following clarification:

The only entity other than the RRE who can update these records is a BCRC CSR/Analyst on behalf of the (verified) beneficiary, for an access to care issue. ORM is not terminated due to entitlement. Updates made by a BCRC Call Center representative based on a call from the RRE will also be noted in this file.

Other notable changes to the Unsolicited Response File include the following:

      • Removal of the following Modifier Type codes from Table 7-3: Modifier Type Code and Modifier Name (page 7-12)
        • BCR
        • ECR
        • RRE
        • WCS
      • Removal of the following Change Reason Description codes from Table 7-4: Change Reason Description (page 7-13)
        • II
        • UK
        • Blank
      • Removal of 15 fields from Table F-2, NGHP Unsolicited Response File Detail Record in Chapter V (page F-2)

Liability Plan Type Change – NOINJ Code

For liability claim reporting, CMS has allowed the use of “NOINJ” code to be used under “extremely limited and specific circumstances” where the type of alleged incident typically has no associated medical care, and the Medicare beneficiary/injured party has not alleged a situation involving medical care or a physical or mental injury.

In User Guide 7.2, CMS made the reporting of such liability records optional (in Chapter IV, Section 6.2.5.2) as follows:

In cases where the reporting of a liability record only meets the criteria for reporting a ‘NOINJ’ diagnosis code in Field 18, the reporting of the record is no longer required. However, it is optional for the RRE to report the record with the ‘NOINJ’ diagnosis code following the previously existing rules in the User Guide…

Commentary

This version of the User Guide contained updates that may have an impact on how an RRE will report and terminate ORM. Of particular note is the addition of statement “and when the beneficiary receives medical treatment related to the injury or illness” for the assumption of ORM. While this does seem to modify the requirement for ORM assumption, there is an ambiguity brought into the decision-making process by the next sentence which states, “Medical payments do not actually have to be paid, nor does a claim need to be submitted, for ORM reporting to be required.” We are aware there is concern around the clarity of this important policy change and the IMPAXX team involved in dialogue with industry groups, such as MARC, attempting to gain further clarification from CMS.

It is also good to note that for Workers’ Compensation claim reports there has always been a threshold exclusion for ORM, which does appear to provide some overlap to this change. An injured worker who has not received medical treatment would likely fall under the “Workers’ Compensation ORM Exclusion” in Chapter III, Section 6.3.1 as follows:

Workers’ compensation claims that meet ALL of the following criteria are excluded from reporting until further notice:

      • The claim is for “medicals only;”
      • The associated “lost time” is no more than the number of days permitted by the applicable workers’ compensation law for “medicals only” (or 7 calendar days if applicable law has no such limit);
      • All payment(s) has/have been made directly to the medical provider; AND
      • Total payment for medicals does not exceed $750.00.

This exclusion, however, does not help us with ORM related to No-Fault plan-type reporting.

Lastly, the ever-evolving Unsolicited Response File continues to generate a lot of concern, but most of that concern involves what data is changed outside of the Section 111 data process and who is allowed to change it. While it seems this new process may still have edits made before going live, CMS held a webinar on June 6, 2023 to address concerns around the Unsolicited Response File and NGHP User Guide 7.2 updates. During this webinar, CMS addressed several areas of concern around the Unsolicited Response File and the surrounding process.  Two important excerpts from the webinar relate to who can update records and what data can be updated as described below:

      • “Why does CMS, via the BCRC, allow someone other than the RRE to make a change to their record? The answer to this is simple and it is about access to care. CMS, and therefore the BCRC, have a responsibility to the beneficiary to ensure that their access to care isn’t impacted by coordination of benefits (COB) information.”
      • “The only information that the BCRC will update is the addition of a termination date for the record. No other information will be updated. If there is other information the beneficiary thinks needs to be updated, the BCRC will refer them back to the RRE.”

For a review of the information presented during the June 6 webinar, the presentation slides and notes can be found here.

For questions regarding this article and/or any changes made in version 7.2 of the User Guide, please don’t hesitate to email us at [email protected]. If you are looking for further guidance on Section 111 reporting compliance, our experienced Medicare Secondary Payer Reporting services team can collaborate with you to customize the compliance experience to meet your unique needs and requirements. Contact us today to learn more.