CMS Issues Section 111 NGHP User Guide Version 6.0

The new Section 111 NGHP User Guide 6.0 (Guide) was issued by CMS on October 5, 2020 and contains several updates as noted below.

  • Chapter III, Section 4.6 of the Guide, CMS has specified what items should be included when calculating the Total Payment Obligation to Claimant (TPOC).  CMS notes that the “TPOC amount includes, but is not limited to,  all Medicare covered and non-covered medical expenses related to the claim(s), indemnity (lost wages, property damages, etc.), attorney fees, set-aside amount (if applicable), payout totals for all annuities rather than cost or present values, settlement advances, lien payments (including repayment of Medicare conditional payments), and amounts forgiven by the carrier/insurer.”  
  • Chapter III, Section 6.5 clarifies that reporting is not required for property only claims or settlements involving indemnity only.  Specifically, the Guide states as follows:

RREs are not required to report liability insurance (including self-insurance) settlements, judgments, awards or other payments for “property damage only” claims which did not claim and/or release medicals or have the effect of releasing medicals.

Similarly, “indemnity-only” settlements, which seek to compensate for non-medical damages, should not be reported. The critical variable to consider is whether or not a settlement releases or has the effect of releasing medicals. If it does, regardless of the allocation (or lack thereof), the settlement must be reported.

  • Chapter V (Appendix J) also includes updates on excluded ICD codes for no-fault reporting in 2021 as well as accepted and excluded ICD-9 and ICD-10 code listings for 2021. 

It is important to incorporate these and other Section 111 Reporting updates and exclusions into your reporting protocols as they become applicable.  This is especially in light of the proposed Civil Monetary Penalties that CMS has noted will be forthcoming.  For questions regarding the above or for any of you Section 111 or Medicare Secondary Payer compliance questions, please contact the NuQuest Settlement Consultant team at: [email protected]