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CMS Updates NGHP User Guide to Version 7.7

October 21, 2024
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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 October 7, 2024. The refreshed User Guide, Version 7.7, contains a major addition to the compliance flags and several other updates.

New Flag Related to Civil Money Penalties

A new compliance flag has been created to provide Responsible Reporting Entities (RREs) with a notice that Ongoing Responsibility for Medicals (ORM) may have been reported late. CMS hinted at the new flag in previous webinars as the CMP Final Rule made the 03 flag (for late reporting of ORM Termination) meaningless, as ORM Termination will not be used in the audit of claims for penalties. In addition, CMS has moved from calling these codes compliance flags to warning flags.

The new warning flag, code 04, will be applied to claim response files with open ORM records when the later date of either the ‘CMS Date of Incident’ on the claim record, or the ‘Part A Add Date’, is greater than 135 calendar days from the Start Date of the RRE’s submission period. This change moves the focus from the ‘ORM Termination Date’ to the ‘CMS Date of Incident’ for the late reporting of ORM. In the table below, RREs should focus on warning flags 01 and 04 for future submissions.

Figure 1- Table G2 – NGHP User Guide 7.7 – Chapter V

Table with reporting warning flags for CMS Section 111 Reporting.

Other Updates

In addition to the 04 warning flag, the following updates were also included:

    • CMS has added a note to section 6.5.1.4 in Chapter III, Policies for wrongful death in liability cases which states:

Note: Settlements, judgments, awards, or other payments obtained entirely under the wrongful death theory of liability, which do not claim and release medicals, or have the effect of releasing medicals, are not required to be reported because Medicare would have no recovery claim against such a payment.

    • An update to Table 7-1 of Chapter I, Introduction has been made to include information for the RRE ID Notification email that is sent once a user completes the initial registration function and the Successful Registration PIN email that is sent once vetting is successful on the Section 111 COB Secure Website (COBSW).

Commentary

While the Final Rule calls for possible money penalties if ORM is reported a year (or more) late, CMS continues to use 135 days, or a quarter and a half, as a warning to the RRE. This should allow the RRE time to understand issues within their reporting process well in advance of reporting claims a year, or longer, late.

While this updated User Guide was published on October 7, 2024, it should be noted that IMPAXX is already in receipt of quarterly submission responses from CMS with the new warning flag 04 included, confirming the code is already in production with CMS.

Lastly, it is important for RREs to understand that the warning flags are generated based on the current submission of claims data and that CMS does not take into consideration any previous submission. For example, an ORM submission that was originally made several quarters ago, but has been resubmitted in the current quarter, will likely return a warning flag in the current submission. This understates the importance of reviewing the results of every quarterly submission and understanding the history of those claims (and previous submission histories) to verify if there is a process concern.

If you have questions about any changes made in User Guide 7.7, or are looking for guidance on Medicare Secondary Payer (MSP) compliance, please don’t hesitate to email our experienced MSP Reporting services team at [email protected].