Tag Archives: NGHP User Guide

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.

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.