CMS Issues New Section 111 NGHP User Guide and PAID Act Technical Alert

CMS has been very busy this month.  In addition to the webinar scheduled for June 23, 2021 to discuss the Provide Accurate Information Directly (PAID) Act.  CMS has now issued a new NGHP User Guide and a PAID Act technical Alert.  The User Guide and the Alert contain significant substantive and technical changes regarding ORM termination and the PAID Act that will impact all Responsible Reporting Entities (RREs).  A summary of these significant updates is outlined below.   

MMSEA Section 111 NGHP User Guide, Version 6.4

Chapter II: Registration Procedures

Chapter 3 now contains the following language regarding the query response record:

The reason for Medicare entitlement is not returned on the query file response. However, starting December 2021, beneficiary Part C (Medicare Advantage Plan) and Part D (Medicare prescription drug coverage) enrollment information will be provided for the past 3 years, as well as the most recent Part A and Part B entitlement dates.

Chapter III: Policy Guidance

Section 6.3.2 includes updated guidance on ORM termination.  CMS previously allowed RREs to terminate ORM only in the following limited circumstances: 

  • Where there is no practical likelihood of associated future medical treatment, an RRE may submit a termination date for ORM if it maintains a statement (hard copy or electronic) signed by the beneficiary’s treating physician that no additional medical items and/or services associated with the claimed injuries will be required;
  • Where the insurer’s responsibility for ORM has been terminated under applicable state law associated with the insurance contract; and
  • Where the insurer’s responsibility for ORM has been terminated per the terms of the pertinent insurance contract, such as maximum coverage benefits.

In response to requests by the Medicare Secondary Payer compliance community to expand the criteria for ORM termination, CMS has now included the following language in the User Guide:

Where there is no practical likelihood of associated future medical treatment, which is reflected by meeting ALL of the following:

  • No claims were paid with any diagnoses codes related to alleged ingestion, implantation, or exposure; and
  • No claims were paid, for any medical item or service related to the case, within five (5) years of the date of service of any such claim; and
  • Treatment did not include, nor were any claims paid related to, a medical implantation or prosthetic device; and
  • The total amount paid by the insurer, for all medical claims related to the case, did not exceed $25,000. 

Although this update is limited by the cap on medicals paid on the claim and the five (5) year waiting period from the last medical payment, this new criteria will provide some much needed relief to RREs especially those in states with lifetime medicals.  It is important to note however, that if circumstances change and any one the above parameters are no longer applicable, the RRE must update the ORM record to reflect this change by placing all zeros in the ORM termination date.  RREs can later terminate ORM if they, once again, fall within these parameters .

Chapter IV: Technical Information

The Event Table included in Section 6.6.4 of the User Guide has been updated to address a claim involving multiple injuries that resolve at differing times.  Specifically, the Event Table now contains guidance on those situations where Ongoing Responsibility for Medical (ORM) ends for one injury due to Total Payment Obligation to Claimant (TPOC) but continues for other injuries on the same claim.  This was also previously addressed by CMS at the Town Hall that took place on April 1, 2021. 

In Section 10.2,  CMS updated the electronic file transfer (EFT) file-naming conventions for inbound and outbound files.

CMS again confirmed that effective December 11, 2021, RREs will receive Part C Medicare Advantage Plan and Part D Medicare prescription drug coverage enrollment information for the past three (3) years.  Specifically,  the Query Response File will be updated to include  the Contract Number, Contract Name, Plan Number, Coordination of Benefits (COB) Address, and Entitlement Dates for the last three (3)years (up to 12 instances) of Part C and Part D coverage.  In addition, the update will also include the most recent Part A and Part B entitlement dates.  CMS notes that the HIPAA Eligibility Wrapper Software (HEW) will also be modified to extract additional information from the response file. 

Chapter V: Appendices

CMS outlines the steps for installing and configuring the HEW software in Chapter V, HEW Query Response File Record-Version 4.0.0, Appendix K of the User Guide.  CMS also reiterates the extent of the Part C and D plan information that will be included in the Query Response File as of December 11, 2021.

A new error code was also added to the Claim Response File Error Code Resolution Table.  Specifically, SP55 error code will be returned when the MSP effective date of the claimant is less than the earliest beneficiary Part A or Part B Entitlement.  An MSP effective date that is an invalid date will also cause the SP55 error.  No correction of the error is necessary, and RREs can resubmit records with this error on the next file submission. 

Technical Alert: PAID Act

Consistent with the updates in the User Guide, CMS addressed the implementation of the PAID Act.  CMS stated  that because of the “significant” change in the query response record and to assist RREs with these changes, it will be supporting a testing period beginning September 13, 2021.  The new version of the HEW application will be available to RREs at that time to test with the query response record format.

As discussed above, information on the HEW software is available in Appendix K of the User Guide as well as in Version 5.5 of the 270/271 Health Care Eligibility Benefit Inquiry and Response Companion Guide for Mandatory Reporting Non-GHP Entities.  These guides are available on the NGHP User Guide page on CMS.gov. 

Conclusion

Some significant takeaways from the above are as follows:

The PAID Act will create material technical and substantive changes to the current query process;

RREs need to work with their current Section 111 vendor to ensure that their reporting system will be updated in the time frame outlined by CMS to include these technical changes and should confirm whether they will incur any additional costs for these changes;

Because the query process will include specific Part C and Part D information, it is critical that RREs develop a process and procedure to address and resolve these conditional payments to avoid potential penalties and costs; and

RRES should update policies and procedures to include the new criteria for ORM termination and track claims where this is applicable.

Version 6.4 of the User Guide and the HEW companion guide can be accessed here.

 In addition, the PAID Act Technical Alert can be accessed here.

As part of our NuQuantics Section 111 Reporting Services, NuQuest will be updating our reporting system as necessary to accommodate these new technical requirements.  If you have questions regarding the above or would like to hear more about our NuQuantics Section 111 Services, please contact the NuQuest Settlement Consultant Team at: [email protected]

Click here to read our most recent blog post on CMS’ PAID Act Webinar.