CMS News to Note

November was a busy month for CMS with the issuance of a new NGHP User Guide, Version 6.1 and multiple alerts.  Below is a brief summary of these updates. 

2021 Recovery Threshold Alert

On November 25, 2020, CMS issued a new alert on the 2021 Recovery Thresholds beginning on January 1, 2021.  The alert notes that these thresholds will remain the same in 2021 at the same $750 limit.  Specifically, the alert provides as follows:

Beginning January 1, 2021, 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 responsibly for medicals. This means that entities are not required to report, and CMS will not seek recovery on settlements, as outlined above. Please note that the liability insurance (including self-insurance) threshold does not apply to settlements for alleged ingestion, implantation, or exposure cases. Information on the methodology used to determine the threshold is provided here.

BCRC NGHP Beneficiary Recovery Process Webinar

 On December 9, 2020, CMS will be hosting a webinar focused on the Medicare Secondary Payer (MSP) recovery process.  The intended audience is listed as attorneys who represent beneficiaries and other beneficiary representatives.  The webinar is noted to be a refresher course on the beneficiary recovery process including use of the Medicare Secondary Payer Recovery Portal, tips and best practices and alternative demand options.   A copy of the notice can be found here. 

New User Guide, Version 6.1/Technical Alert

The new Section 111 NGHP User Guide, Version 6.1, includes changes to the ‘SP31’ error notice. This error notice is returned when a record is submitted to CMS prior to the injured party’s Medicare eligibility date.  The record is then rejected, and the reporting entity is instructed to resubmit the record on their next quarterly submission.  Chapter IV (Technical Guidance) of the new User Guide states that effective April 5, 2021, CMS will eliminate this error notice and, instead, the reporting party will receive Disposition Code ‘03.’

In addition, Chapter V of the new User Guide includes numerous error codes that have resulted in a record being rejected by CMS.  Effective April 5, 2021, these codes will become “soft” errors and will no longer result in the record being rejected by CMS.  CMS notes that RREs should correct these errors and resubmit the record on their next quarterly submission.  These “soft” errors are fully listed in Appendix F of the new User Guide which can be found here. 

CMS also notes that ‘soft” edits will be applied and added to Claim Input File Detail Records when no-fault insurance claims have policy limits of less than $1,000. These records will be accepted, but a new CP13 error will be returned on response files. 

CMS notes these changes as follows:

  • A new “soft” edit will be added and applied to NGHP Claim Input File Detail Record files when users submit a no-fault insurance claim where the policy limit is less than $1,000.00. The input files will be accepted but a new CP13 error will be returned on the response files. Direct Data Entry (DDE) submitters will see a message on the Insurance Information page but will be able to proceed with data entry without correcting (Appendix F).
  • Several Section 111 input record errors that would cause a record to reject will become “soft” errors; that is, they will no longer cause the input records to be rejected. RREs, however, will continue to receive the errors on their response files, and they should correct and resubmit on their next quarterly file submission.
  • The errors include: CC05, CC11, CC12, CC13, CC25, CC31, CC32, CC33, CC45, CC51, CC52, CC53, CC65, CC71, CC72, CC73, CI02, CI03, CI25, CP03, CP06, CP07, CP08, CP09, CP10, CP13 (new), CR11, CR12, CR13, CR14, CR31, CR32, CR33, CR 34, CR51, CR52, CR53, CR54, CR71, CR72, CR73, CR 74, CR91, CR92, CR93, CR94, and TN30 (Appendix F).

In conjunction with the new NGHP User Guide, CMS also issued a Technical Alert describing the above in further detail.  A copy of the Alert can be found here

Should you have any questions regarding the above or for any of your Medicare Secondary Compliance needs, please contact the Settlement Consultant team at: [email protected]