Author Archives: Frank Fairchok

CMS Releases NGHP Section 111 User Guide Version 5.4

As 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 October 1, 2018, CMS released an updated Non Group Health Plan (NGHP) User Guide, version number 5.4. This release contains several updates that are summarized here.

The first update is a disclosure regarding the Paper Reduction Act (PRA). This disclosure, found on page iii of Chapter I – Introduction and Overview, relates to the PRA of 1995, an amendment to PRA of 1980, intended to reduce the paperwork burden on businesses and citizens imposed by federal government agencies. This portion of the update does not have any impact on NGHP Section 111 reporting and is for informational purposes only.

The next update is a reminder from CMS that Responsible Reporting Entities (RREs) should submit the policy number uniformly and with a consistent format so that updates are applied to recovery cases correctly. The update states:

“To ensure updates are applied to recovery cases appropriately, RREs are asked to submit the policy number uniformly with a consistent format. When sending updates, enter the policy number exactly as it was entered on the original submission, whether blank, zeros, or a full policy number (Appendix A, Claim Input File, Field 54).”

Please note, our analysis of this change determines that the wording above is inconsistent with other areas of the User Guide. Specifically, the policy number field cannot be submitted to CMS as “blank” as stated above, which would mean padding the field with spaces in the claim input detail record. Optum has confirmed with the BCRC that no changes have occurred making policy number a non-required field. The policy number must contain at least a three character length valid policy number or be completed with all zeros. Submission of a blank policy number will result in the claim being rejected by CMS with the CP04 error code. Clients utilizing Optum’s MedicareConnect platform for NGHP Section 111 reporting can rest assured that our validations will properly evaluate your data, allowing for continued 100 percent acceptance rate for submitted claims.

The next update occurs in the Chapter V appendices. Appendix I lists ICD-9 and ICD-10 diagnosis codes not allowed for NGHP Section 111. Likewise, Appendix J contains ICD-9 and ICD-10 diagnosis codes not allowed on no-fault plan insurance type claims for NGHP Section 111. These updates include the following:

  • Placement of decimals for the ICD-10 Excluded “Y” diagnosis codes has been corrected (Appendix I).
  • The excluded and no-fault excluded ICD-10 diagnosis codes have been updated for 2019 (Appendix I and Appendix J).

The last update involves a contact name change in multiple chapters of the User Guide. This change removes Jeremy Farquhar’s contact information and includes a new escalation contact due to Jeremy’s departure from the BCRC in August 2018. In cases needing escalation, the new EDI Director is Angel Pagan, available via phone at (646) 458-2121 or e-mail at apagan@ehmedicare.com.

As a senior leader in mandatory insurer reporting, Optum Settlement Solutions looks forward to working with Mr. Pagan in providing our clients with MSP compliance industry leading advice, expertise, support and services.

Optum would also like to take this opportunity to thank Mr. Farquhar for the many years of incredible support he provided Optum and the entire NGHP community. We wish him the very best in the future.

Click here to access the updated User Guide.

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