Tag Archives: CMS releases

CMS Releases NGHP Section 111 User Guide v5.2

CMS has released an updated NGHP User Guide, version number 5.2. The update clarifies MIR Section 111 reporting thresholds initially addressed in a published alert by CMS Financial Services Group posted to the Non-Group Health Plan Recovery site on November 15, 2016 entitled “2017 Recovery Thresholds for Certain Liability Insurance, No-Fault Insurance, and Workers’ Compensation Settlements, Judgments, Awards or Other Payments”. The changes to thresholds are summarized below.

For Section 111 reporting, the Centers for Medicare & Medicaid Services (CMS) has changed the minimum reportable Total Payment Obligation to the Claimant (TPOC) amounts for liability insurance (including self-insurance), no-fault insurance, and workers’ compensation claims.

  • Liability is changing from $1000 to $750 for TPOC Dates of 1/1/2017 and subsequent.
  • No-Fault is changing from $0 to $750 for TPOC Dates of 10/1/2016 and subsequent.
  • Workers’ Compensation (WC) is changing from $300 to $750 for TPOC Dates of 10/1/2016 and subsequent.

TPOC amounts exceeding these thresholds must be reported. However, TPOC amounts less than the specified threshold may be reported and will be accepted.

The logic for the CJ07 error has been changed such that a TPOC of any amount will be accepted for all types of TPOCs, including liability TPOCs. The CJ07 error will continue to be returned for a liability, workers’ compensation, or no-fault claim report where the ORM Indicator is set to “N” and the cumulative TPOC amount is zero.

We are able to provide a consolidated PDF file of all the updated chapters upon request. Please contact us at JustRegister@optum.com if you would like to receive this consolidated, searchable file. For more information, please email JustRegister@optum.com.

Modification of Query Matching Criteria for Partial SSNs

Post by Frank Fairchok MedicareConnect℠ Senior Manager

Post by
Frank Fairchok
MedicareConnect℠ Senior Manager

CMS has released an alert to notify all users that they have modified the matching criteria for queries where the full Social Security Number could not be obtained and a five-digit SSN was provided. This change, which is effective immediately, fixes an issue where false beneficiary matches were made when the partial SSN and only three of the other four query fields were matched with the existing full SSN logic. CMS will now utilize the partial SSN and the other four query elements as detailed here:

  • First initial of the first name
  • First 6 characters of the last name
  • Date of birth (DOB)
  • Gender

Per CMS, when an exact match on the partial SSN is found, then all of the other four remaining data elements must be matched to the individual exactly. However the matching criteria for HICNs and full SSNs will remain the same.

It is important to note that CMS encourages RREs to submit the HICN or full SSN when it is available to ensure the most accurate match is obtained. CMS reminds RREs in this alert that failure to match to a Medicare beneficiary with the full or partial SSN does not negate the RRE’s Section 111 mandatory reporting requirement when a reportable claim exists.

This alert, dated and released on June 18, 2015, can be found at the following address: https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Non-Group-Health-Plans/Downloads/New-Downloads/Technical-Alert-Modification-of-Matching-Criteria-Used-When-Reporting-Partial-Social-Security-Numbers-for-Liability-Insurance.pdf

For more information, please contact Frank Fairchok, Senior Manager of MedicareConnect at Frank.Fairchok@helioscomp.com.