CMS issues updated Non-Group Health Plan (NGHP) User Guide regarding Section 111 Reporting, Version 5.9

July 6, 2020 by Patrick Czuprynski, JD, MSCC, CMSP

On 6/29/2020, Medicare issued an update to its NGHP User Guide. The following is a summary of those updates:

Chapter III: Policy Guidance

  • Sections 6.4.2, 6.4.3 and 6.4.4 were updated to remind Responsible Reporting Entities(RRE) that the $750 settlement reporting threshold does not apply to liability settlements associated for non-traumatic injuries.  For example, settlements involving alleged ingestion, implantation or exposure cases must be reported.  This is regardless of the settlement amount.

Chapter IV: Technical information

  • Sections 6.4.2, 6.4.3 and 6.4.4 were updated to remind Responsible Reporting Entities) that the $750 settlement reporting threshold does not apply to liability settlements associated for non-traumatic injuries.  For example, settlements involving alleged ingestion, implantation or exposure cases must be reported.  This is regardless of the settlement amount.
  • Section 7.3.2 Maximum settlement amount threshold error was increase to $99.999.999.99.  This error is produced if total cumulative TPOCs exceed this amount.
  • Section 6.7.1 in situations involving no- fault liability policies that have coverage under Med-Pay and Personal Injury Protection (PIP), policy limit exhaustion for ORM requires exhaustion of both the Med-Pay policy and the PIP policy. 

If a settlement surpasses the $99,999,999.99 threshold error, the RRE needs to obtain involvement of their EDI representative to resolve the issue.

Chapter IV: Technical information

  • Appendix A was updated to include situations involving no- fault liability policies that have coverage under Med-Pay and Personal Injury Protection (PIP). In these circumstances, Policy limit exhaustion for ORM requires exhaustion of both the Med-Pay policy and the PIP policy. 
  • Appendix I was updated to remove Certain ICD10 codes and ICD9 codes that were previously excluded from reporting.  From our review it appears certain conditional associated with the heart (I48.0-I48.92 and 427.31) are not available for reporting conditions associated with a NGHP claim.
  • Appendix F, Table F-4 was updated to correct the CR02 claim response file error code field number. This was changed from filed 65 to field 85.  This means if you receive error code CR02 from Medicare associated with your claim, Field 85 in the claim input file may need to be corrected or adjusted.

These changes do not appear to have a major impact on the industry as a whole. However, RREs or their Third Party Administrator’s reporting Section 111 data should be updating their system protocols to incorporate Medicare’s reminders and recommendations. As more updates are provided by Medicare, we will keep you posted. For any questions, please contact: SettlementConsultants@mynuquest.com