Author: Iliana A Gallegos,
On October 6, 2014, the Centers for Medicare & Medicaid Services (CMS) revised the
MMSEA Section 111 NGHP User Guide. Of note, version 4.3 of User Guide was updated
to reflect the delay of ICD-10 diagnosis code implementation from October 2014 to 2015,
pursuant to the Protecting Access to Medicare Act of 2014 signed into law on April 1,
2014. CMS further clarified that when implemented, RREs will no longer be allowed to
report ICD-10 “Z” codes, which represents the reason(s) for an encounter.
As the Department of Health & Human Services adopted a policy treating same-sex
marriages on the same terms as opposite-sex marriages, any same-sex marriage legally
entered into in a U.S. jurisdiction that recognizes the marriage will be recognized.
Effective January 1, 2015, the following rules will apply with respect to the term
“spouse” under the MSP Working Aged provisions, which include both opposite-sex and
• If an individual is entitled to Medicare as a spouse based on the Social Security
Administration’s rules, that individual is a “spouse” for purposes of the MSP
Working Aged provisions.
• If a marriage is valid in the jurisdiction in which it was performed, both parties to
the marriage are “spouses” for purposes of the MSP Working Aged provisions.
• Where an employer, insurer, third party administrator, GHP, or other plan sponsor has a broader or more inclusive definition of spouse for purposes of its GHP
arrangement, it may (but is not required to) assume primary payment responsibility
for the “spouse” in question. If such an individual is reported as a “spouse” pursuant
to MMSEA Section 111, Medicare will pay accordingly and pursue recovery, if
Additional revisions included the following:
• Change Request (CR) 12178: Missing excluded ICD-10 codes added to Appendix
J, Chapter V.
• CR 12590: For ICD-10 changes, field numbering/layout discrepancies were
corrected in Table A2 (Claim Input File Supplementary Information), Chapter V.
• CR 12170: Two threshold error checks for the Claim Input File were implemented
in July 2011. These errors are related to the dollar values reported for both the
cumulative TPOC amounts and the No-Fault Insurance Limit (Chapter IV).
• CR 12636: The Appendix L alerts table has been removed and replaced with links
to the Section 111 web site, which posts all current alerts and stores all archived
alerts (Chapter V).
• CR 12829: Updated CS field numbers in Table F-4 (Claim Response File Error
Code Resolution Table) to accommodate ICD-10 revisions (Chapter V)
On October 27, 2014, CMS issued a Technical Alert titled Response File Naming
Convention Change for Liability Insurance (Including Self-Insurance), No-Fault
Insurance, and Worker’s Compensation. Effective April 6, 2015, the naming convention
used for the Claim Response, TIN Response and Query Response Files will be modified.
On November 12, 2014, a Technical Alert titled Option for Responsible Reporting
Entities (RREs) to Submit Recovery Agent Information for MSP Recovery Related. Some
NGHP RREs use a separate agent to assist with tasks related to MSP recovery demands.
The current Section 111 file layouts, however, do not accommodate separate name and
address fields for this purpose. As a workaround, RREs were allowed to submit Third
Party Administration information in existing Section 111 TIN Reference File fields or
Direct Data Entry fields. Effective July 13, 2015, CMS will be implementing a permanent
solution for RREs to submit their recovery agent information in designated fields on
the TIN Reference File and Direct Data Entry claim submissions. The submission of
recovery agent information will continue to be an option, and the current workaround for recovery agent information will continue to be an option, and the current workaround for
submission of a Third Party Administrator Address should no longer be used. RREs are
encouraged to use the new reporting methodology as both the RRE and recovery agent
will be copied on recovery correspondence.