Tag Archives: NGHP User Guide

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.

CMS Releases Updated NGHP User Guide Version 4.6

CMS released an updated User Guide for NGHPs, version 4.6, on April 6, 2015.

The update contained in the new version appears to have been previously released on a technical alert dated November 25, 2014 regarding the use of partial Social Security Numbers for NGHP Section 111 reporting. While these edits are bringing the User Guide up-to-date with the alerts, Helios encourages RREs and claim administrators to review the new User Guide in its entirety to ensure compliance.

The change noted in the revision history of the document lists the following items:

CR13592: In instances where a duplicate is returned, indicated by the disposition code “DP” or messaging on the Beneficiary Not Found page, users are instructed on what actions to take to remain in compliance with reporting requirements (Chapters IV & V). See Chapter 1 for details.

This change request relates to a scenario where a DP disposition code is returned by CMS when a 5-digit SSN is used to query beneficiary status, but cannot be matched to a single record. The resolution, as detailed in the User Guide 4.6 and the original alert, includes validating all the query related fields, submitting the full 9-digit SSN (if available) and then contacting the BCRC at 1-855-798-2627 if a distinct match can still not be made.

The updated chapters of the User Guide 4.6 can be found here.

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

For a consolidated, single PDF file version of the User Guide 4.6, please contact Helios at JustRegister@Helioscomp.com.