CMS Updates NGHP User Guide & NGHP Applicable Plan Appeals Guide

by F. Fairchok

The Centers for Medicare & Medicaid Services (CMS) published updates to both the Non-Group Health Plan (NGHP) Section 111 Reporting User Guide and the Non-Group Health Plan (NGHP) Applicable Plan Reference Guide on July 1, 2024.

NGHP Section 111 User Guide

The updated User Guide, Version 7.6, contains changes related to the clarification of cumulative injuries and information on how to resolve TIN address errors.

Cumulative Injuries

CMS added the following note to help clarify the definition of a cumulative injury:

Note: Cumulative injury refers to those categories of injuries that may persist or grow in severity, intensity, or pain but for which a formal diagnosis may not occur until a later date. Examples of cumulative injuries include, but are not limited to, carpal tunnel syndrome, or back pain that is not the result of an acute trauma. Exposure, ingestion, and inhalation injuries are not considered cumulative injuries for purposes of calculating DOI or any other reporting requirements.

Resolving TIN Address Errors

CMS also included information to help Responsible Reporting Entities (RREs) prevent address validation issues that may lead to claim rejection in the reporting process. CMS encourages the use of postal software and online tools to pre-validate TIN addresses prior to submission. An example of which is the USPS lookup tool.

In addition, CMS provided guidance that if an address fails validation with the USPS that RREs must contact their local USPS office to correct the issue. The User Guide urges RREs to do so immediately as TIN errors delay MSP records from posting, which could create a late report and lead to Civil Money Penalties.

NGHP Applicable Plan Reference Guide

The Applicable Plan Reference Guide Version 1.1 contains updates relating to documentation needed to appeal based on the exhaustion of benefits. Section 4.1.1, Termination of ORM Due to Benefits Exhaustion, states:

This appeal applies if the applicable plan does not have primary payment responsibility for some or all the dates of service included in the demand on the basis that the workers’ compensation or no-fault policy limit has been reached and benefits have exhausted as outlined in the policy or plan.

Further, it is indicated in Section 4.1.1 that if the benefit exhaust date has not been updated via Section 111 reporting, the following documentation is needed:

1. 1. 1. Cover letter.
      2. Payment or billing ledger which demonstrates benefits were appropriately exhausted that accumulates to the reported policy limit.
      3. Appropriate exhaustion means payment for specific services rendered by physician and/or facility, or reimbursable to the beneficiary. The documentation must contain the following:

• • • • Date(s) of service
      • The total amount of claim(s) billed (billed amount)
      • Amount paid to provider
      • Provider name
      • Name of recipient of processed claim or payment (e.g. if reimbursement was made to the beneficiary for out-of-pocket payment)
      • Date payment was processed or issued

If the benefit exhaust date was updated via Section 111 reporting, the requirement for item number two above changes instead to a written confirmation of the benefit exhaust date, and that the benefit exhaust date has been reported through the Section 111 reporting process.

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