CMS NGHP User Guide 6.2

Picture of a pen on top of paper with numbers

In less than four months, CMS has issued three revised versions of the Non-Group Health Plan (NGHP) Section 111 User Guide.  The most recent version, Guide 6.2, includes some of the following updates:

  • In Chapter IV, Section 6.7.1 of the Guide, CMS notes that those Responsible Report Entities (RREs) who can identify a future Ongoing Responsibility for Medicals (ORM) termination date based on terms of the insurance contact,  can enter this future date up to 75 years from the current date. CMS further notes that RREs should not submit an expected, anticipated, or contingent ORM termination date as this should be based upon a date certain.  Prior versions of the Guide only allowed RREs to post a future ORM termination date up to 6 months in advance without being flagged. 
  • CMS now considers the Policy Number Field (Field 54) as a Key Field.  In order for CMS to update or delete a record, the policy number must match the number on the previously accepted claim.  If an RRE need to update a policy number, the action type should be delete/add rather than an update.
  • CMS has updated data transmission methods.  Specifically, CMS notes as follows:

As part of CMS’ commitment to the modernization of the Coordination of Benefits & Recovery (COB&R) operating environment, changes are being implemented to move certain electronic file transfer data exchanges to the CMS Enterprise File Transfer (EFT) protocol. As part of this change the exchange of data with the COB&R program via Connect: Direct to GHINY SNODE will be discontinued. The final cutover is targeted to occur in April 2021. File naming conventions and other references have been updated in this guide. Contact your EDI Representative for details.

  • CMS also confirmed the current review thresholds for trauma-based liability settlements will remain $750 and $750 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.

We can expect yet another update to the NGHP User Guide sometime in April per CMS.  NuQuest will continue to keep you updated on these developments.  Should you have any questions regarding the above or for any of your Section 111 Medicare Compliance Needs, please contact the Settlement Consultant Team at [email protected]

News to Note

CMS has issued an updated NGHP User Guide, Version 6.2.  Some of the updates include the following:

  • The ability for Responsible Reporting Entities to terminate ORM based upon the terms of the insurance contract up to 75 years in the future.  CMS is quick not note that this future ORM termination date needs to be a date certain and should not be a date anticipated, expected, or contingent on other factors.
  • CMS has eliminated one method of data transfer.  This change will not impact the majority of RREs.  For further information CMS suggests RREs should contact their EDI representatives. 
  • CMS also confirmed the current review thresholds for trauma-based liability settlements will remain $750 and $750 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.
  • CMS now considers the Policy Number Field (Field 54) as a Key Field.  In order for CMS to update or delete a record, the policy number must match the number on the previously accepted claim.  If an RRE need to update a policy number, the action type should be delete/add rather than an update.

Medication Pricing Change

The AWP Redbook pricing for Sertraline, the generic version of Zoloft, 25mg, 50mg and 100mg have all decreased.  Originally pills were priced in the range of $2.70 each and are now between $0.41 and $0.54 cents.  NuQuest can provide a report listing MSAs that remain open that include this medication should you want to amend the document for further savings.  Please let me know if you would be interested in this report.

Money Savings

According to Lottery USA, the odds of winning the Mega Millions Jackpot are 1 in 302.6 million and the odds of winning the Powerball jackpot are 1 in 292.2 million- But the odds of saving thousands of dollars on Medicare lien payment recoveries through NuQuest are 1 in 1.  We have worked with clients to reopen cases where lien payments have been made or deadlines for disputes were missed.  This resulted in our clients receiving some or all of these monies back.  Our lien recovery project, which are part of our Section 111 Systems Review, truly does provide significant saving opportunities.  If you would like to set up brief call  to discuss this service further, please just let me know.