CMS Publishes NGHP Section 111 User Guide Version 7.5
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 April 1, 2024. This updated User Guide, version 7.5, contains changes related to the submission of Workers’ Compensation Medicare Set-Aside (WCMSA) information that will become effective for all records submitted with a Total Payment Obligation to the Claimant (TPOC) on or after April 4, 2025.
Fields Added for WCMSA Data
In this update, the Chapter V appendices have been modified to show the future state of the Claim Input File Detail Record. Fields 37 through 43 have been added to allow for the WCMSA data to be reported and are marked with an asterisk to indicate this is the future state of the Claim Input File Detail Record. Once these fields are in effect, the User Guide will be updated to renumber the fields and synchronize the ending position for the newly added fields and all field that follow. The fields were added between the ICD Diagnosis Code section and the unused Product Liability section in the layout.
Error Codes
Appendix G has several updates to include new error codes related to the reporting of the WCMSA information. Table G-3 now includes error code classification CW for Claim WCMSA Information, and the codes will be effective on April 4, 2025. Table G-4 includes twelve new error codes of CW01 through CW12, and it is important to note that these errors are hard errors that will cause a claim to be rejected by CMS.
Threshold Update
CMS has included the following update to the TPOC reporting threshold, maintaining the existing limit into 2024:
“As of January 1, 2024, 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 responsibility for medicals.”
Commentary
Version 7.5 of the User Guide continues the evolution of Non-Group Health Plan Section 111 reporting to include Workers Compensation Medicare Set-Aside data. This new requirement will trigger many updates throughout the industry as claim systems will need to be updated to accept and store this data. In addition, all file specifications will need to be modified to transmit the data, not just to CMS but also where data is shared with reporting agents.
With Civil Money Penalties also moving forward in 2025, it is critical for Responsible Reporting Entities to confirm their capability to report the WCMSA data correctly and in a timely manner. Claims that are rejected by CMS because of these new requirements may be at risk for being reported late. In addition, if a submitted claim file hits the 20% error threshold, all the claims in that file will also be rejected by CMS potentially placing them all at risk for late reporting.
CMS continues to provide information regarding the expansion of TPOC reporting to include WCMSA information and will be hosting has another webinar on April 16, 2024. For information relating to this webinar please see our article CMS to Review Expansion of TPOC Reporting During Webinar on April 16.
If you have questions about changes made in version 7.5 of the User Guide, or are looking for further guidance on Section 111 reporting compliance, please don’t hesitate to email our experienced Medicare Secondary Payer Reporting services team at [email protected].