Updated Section 111 NGHP Model Language

CMS has released an updated Section 111 Model Language form to assist Responsible Reporting Entities (RREs) in obtaining critical information needed to determine claimants’ Medicare eligibility status.   A copy of this form can be found here.  This form differs slightly from the prior version.  These differences include additional language stating  “[if] you are unable to provide your Medicare Number and uncomfortable with providing your full Social Security Number (SSN), you have the option to provide the last 5 digits of your SSN.”  Further, CMS took out the reference to Medicare enrollment in Part A and Part B and provided more general language asking if the claimant has been enrolled in “Medicare.”  This provides the option for the claimant to address potential Medicare Advantage/Part D plans. 

The updated form is a timely tool for RREs in light of the looming rule regarding civil monetary penalties.  As noted in the proposed rule, RREs must make a good faith effort to obtain the data necessary to determine Medicare eligibility status and these efforts must be clearly documented.  RREs should begin incorporating this updated form and other necessary measures to ensure that they are collecting the information needed for Section 111 NGHP Reporting prior to case closure.  Should you have additional questions concerning the above or if you would like to discuss our Section 111 Service options, please contact the NuQuest Settlement Consultant Team at [email protected].