CMS releases NGHP Section 111 User Guide Version 5.5

CMS Issues MemoAs an established Medicare Secondary Payer (MSP) compliance services provider, one of our goals is to keep clients, and the property and casualty insurance industry, informed of changes affecting MSP compliance. On January 4, 2019, CMS released an updated Non Group Health Plan (NGHP) User Guide, version number 5.5. Click here to access the updated User Guide. The following is a summary of the updates.

The first update is included in Chapter III, Policy and Guidance, and states that the threshold limit for reporting liability insurance settlements, judgments, awards and other payments will remain at $750 for 2019. In addition CMS will maintain the $750 threshold for reporting no-fault insurance and workers’ compensation settlements, where the no-fault insurer or workers’ compensation entity does not otherwise have ongoing responsibility for medicals (ORM). This update brings the User Guide in alignment with the November 15, 2018 alert from the Financial Services Group.

Three other updates are included in the Chapter V Appendices. There is a change in language for the funding delayed beyond TPOC start date fields one through five as follows:

  • Prior version: “If funding for the TPOC Amount 1 is delayed, provide actual or estimated date of funding.”
  • New version: “If funding is determined after the settlement date (in TPOC Date field), provide actual or estimated date of funding determination.”

This change indicates CMS is interested in when the date of funding is determined rather than actually disbursed for TPOCs delayed beyond the initial settlement date. This wording is consistent across all five of the funding delayed beyond TPOC start date fields – field 82 in table A3 and fields 95, 98, 101 and 104 in table A5 of the Claim Input File Auxiliary Record. (Note the Summary of Version 5.5 Updates at the beginning of Chapter V incorrectly list all five fields as located in table A3 for the Claim Input File Detail Record.)

The last two updates in the Chapter V Appendices include a change to revision and version history, indicating a limit of versions to the last four releases. Also, the ICD-9 and ICD-10 tables in Appendices I and J have been updated to match the data available through the Section 111 MRA application on the Benefits Coordination & Recovery Center website.

Optum clients utilizing MedicareConnect for NGHP Section 111 reporting will be guided to use the correct ICD codes for 2019 submissions as any excluded codes will result in an error that will prevent the claim from being submitted to CMS in the quarterly reporting file.

Should you have any questions about the information presented above, please contact Frank Fairchok via email at frank.fairchok@optum.com.