The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 NGHP User Guide (Version 7.7, October 7, 2024) regarding Section 111 reporting related to non-group health plans (NGHPs) (liability, no-fault and workers' compensation).

As usual, CMS lists the new updates in the beginning of each User Guide chapter in a "Summary" page. Reviewing these pages indicates that updates were made to Chapter I (Introduction and Overview), Chapter II (Registration Procedures), Chapter III (Policy Guidance), Chapter IV (Technical Information), and Chapter V (Appendices).

As outlined more fully below, CMS made several updates including:

• New system generated e-mail notifications;
• TPOCs/wrongful death;
• New "04" warning flag; and
• Disposition code "03" description - clarifications

The following provides an overview of the changes made in NGHP User Guide (Version 7.7):

Two new system-generated e-mail notifications

CMS's updates on this item impact Chapters I, II, and IV. In a nutshell, the table describing system-generated emails has been updated to introduce two new automated e-mail notifications noted by CMS as: (1) RRE ID Notification and (2) Successful Registration PIN.

This update is outlined in more detail as follows:

In the Chapter I Summary page, CMS states: "The table describing system-generated emails has been updated to include information for the RRE ID Notification email that is sent once a user completes the initial registration function and the Successful Registration PIN email that is sent once vetting is successful on the Section 111 COB Secure Website (COBSW) (Table 7-1)."^[1]A similar update is noted in the Chapter II Summary page, this time with reference to Table 6-4.^[2]Likewise, similar verbiage is contained in the Chapter IV Summary page, with reference, in this instance, to Table 12-1.^[3]

In all three scenarios above, the tables to which updates have been applied are the same but repeated within different sections of the User Guide with all three updates referencing the two newly introduced automated email notifications as follows:

RRE ID Notification -- for this new notification the Authorized Representative is noted as the recipient where CMS outlines the purpose of the email as, "Generated after a user completes the initial registration function on the COBSW. The email will contain the user's assigned RRE ID, contact information for their assigned EDI Representative, and next steps in the registration and account setup processes."^[4]

Successful Registration PIN -- for this new notification the Authorized Representative is also noted as the recipient where CMS outlines the purpose of the email as, "Generated after successful vetting. The email will contain the PIN and should be provided to the AM to complete the account setup."^[5]

Authors' comments:

From the authors' perspective, both of these new automated email notifications will likely be quite helpful in relation to the Section 111 registration process and will presumably be well received by most Section 111 RREs.

Regarding the "RRE ID Notification" email, the information which will now be shared with the RRE's Authorized Representative via email was information that would previously have only been displayed on screen within the Section 111 COBSW upon completion of the "initial registration" portion of the registration process.^[6]In the past, if the individual who completed the "initial registration" failed to make note of this information upon completion of that first phase of the registration process, they would not have had an easy way to determine their newly created RRE ID nor their assigned EDI Representative so the new email notification should help to ensure that the Authorized Representative retains those important pieces of information.

As for the "Successful Registration PIN" email, this is something which will likely help many new RREs by expediting the completion of the second "account setup" portion of the registration process. In the past, after completing the "initial registration" phase of the registration process, an Authorized Representative would need to wait to receive their 4-digit PIN via a letter delivered by the USPS.^[7] However, often times, were a request made to the assigned EDI Representative, they would respond by emailing the PIN directly to the Authorized Representative in order to avoid waiting for the letter to come in the mail. Now, with CMS's newly implemented email notification, this email will be generated and sent to the Authorized Representative in an automated fashion once CMS has completed vetting the information provided during "initial registration" and this should allow for more expedient completion of registration process overall.

TPOCs - wrongful death

This update impacts Chapter III. In this regard, CMS notes the following in Chapter III's Summary page: "For clarification, a note has been added to indicate that settlements, judgments, awards, or other payments obtained entirely under the wrongful death theory of liability, which do not claim and release medicals, or have the effect of releasing medicals, are not required to be reported (Section 6.5.1.4)."^[8]

Pursuant to this change, the exact language added to Section 6.5.1.4 now reads as follows: "Note: Settlements, judgments, awards, or other payments obtained entirely under the wrongful death theory of liability, which do not claim and release medicals, or have the effect of releasing medicals, are not required to be reported because Medicare would have no recovery claim against such a payment."^[9]

Authors' comments:

The reportability of wrongful death claims, in the authors' experience, has historically been a topic which has often elicited questions from RREs. Most recently, CMS addressed this topic during the Question and Answer portion of CMS's September 12, 2024 Section 111 NGHP reporting webinar, which the authors also covered within their article summarizing that session (CMS covers NGHP Section 111 reporting issues in September 12 webinar). As outlined in the authors' prior article, CMS provided similar feedback to that outlined above as part of its new User Guide updates. From the authors' perspective, many RREs will likely welcome CMS's published guidance on this topic moving forward.

New "04 Warning Flag"

This update impacts Chapters IV and V. In a nutshell, CMS has added a new "warning flag" (what CMS would have previously referred to as a "compliance flag") which will be generated upon CMS receipt of a delayed initial ORM report. This is similar to CMS's preexisting "01" and "03" "warning flags" which are generated upon CMS's receipt of delayed TPOC and ORM termination respectively.

In terms of the updates, CMS describes the following changes as part of Chapter IV's Summary page: "For NGHP claim files, a new "04" warning flag will be applied to claim response files with open ORM records when the later date of either the CMS Date of Incident on the claim record or the Part A Add Date is greater than 135 calendar days from the Start Date of the RRE's submission period. Additionally, compliance flag fields have been renamed warning flag (Sections 6.1 and 6.9.1 and Chapter 7)."^[10]Similar verbiage is noted in Chapter V, this time with reference to Appendix C and Appendix G.^[11]

In addition to the above referenced rewording of all prior references to "compliance flags" to read as "warning flags" throughout Chapters IV and V, the following language was added within Chapter IV, Section 7.4 in relation the newly introduced "04" "warning flag:"

"You may receive a value of '04' in a Warning Flag field, which indicates that the submitted add record with ORM was identified as late based on the CMS Date of Incident or Part A Add Date. '04' is put in the first available Warning Flag field when the later date of either the CMS Date of Incident (on the incoming claim input file record) or the Part A Add Date is greater than 135 calendar days from the start date of the RRE's submission period."^[12]

Furthermore, a new entry was added to table G-2 (Claim Response File Warning Flag Codes) within Chapter V which provides the following description: "The later date of either the CMS Date of Incident (on the incoming claim input file record) or the Part A Add Date is greater than 135 calendar days from the Start Date of the RRE's submission period."^[13]

Authors' Comments

The authors find this update particularly interesting in that CMS's former "compliance flag" process (now the "warning flag" process) is presently out of sync with CMS's Section 111 civil money penalties (CMPs) regulations published as part of the agency's CMPs "final rule." Specifically, per CMS's CMPs final rule regulations, CMS has indicated that reporting of both TPOC and ORM triggers would be considered untimely if not reported "within 1 year of… the date a settlement, judgment, award, or other payment determination was made (or the funding of a settlement, judgment, award, or other payment, if delayed), or the date when an entity's Ongoing Responsibility for Medicals (ORM) became effective."^[14]

However, CMS's former "compliance flag" (now a "warning flag") process will trigger a "warning flag" whenever a TPOC is reported more than 135 days subsequent to the TPOC date ("01" "warning flag") and now also whenever an ORM report is submitted more than 135 days subsequent to the CMS date of incident or the beneficiary's Part A Medicare entitlement date if subsequent to the date of incident ("04" "warning flag").^[15]

Subsequent to the publication of CMS's CMPs final rule, the authors had been advised that a number of RREs anticipated that CMS might revise their "compliance flag" process to ensure that these flags were triggered based on the new one year timely filing deadline as stated in the CMPs final rule, as opposed to the old 135 day filing deadline, which CMS had documented via the "compliance flag" process prior to the publication of the CMPs "final rule." However, when CMS was questioned about this during their January 18, 2024 CMPs webinar, the agency indicated that it had no plans to make any changes to their current "compliance flag" process in relation to the one-year timely filing guidelines outlined within its CMPs final rule.^[16]As such, rather than applying updates to the timeframes within which these "compliance flags"/"warning flags" would be generated, CMS have now added a new flag in relation to delayed initial ORM reports and retained the old 135 day timeframe for generation for this and other related flags.

While the authors are not privy to the exacting reasons behind CMS's determination to add this new warning flag, from the authors' view, it seems as if CMS may have decided that, rather than update their process to trigger "compliance flags"/"warning flags" upon receipt of a report submitted more than one year after the reporting trigger (TPOC or ORM) occurred (which is the basis for potential CMPs), the agency would simply relabel the flags as "warning flags" and generate them where there may have been a slight delay, notwithstanding the fact that an RRE may still be well within the 1 year timely filing deadline under CMS's CMPs regulations. Again, while the authors have no information regarding CMS's reasoning to retain the 135 day timeframe for generation of the "compliance flags"/"warning flags," one possible explanation is that perhaps the agency feels that drawing attention to even these scenarios where a slight delay in reporting may occur (but for which assessment of a CMP would not yet apply) may be helpful in reminding RREs of the importance of consistent timely reporting of their data in order to ultimately avoid the assessment of penalties.

With all that being said, it is also notable that CMS appears to have, presumably inadvertently, neglected to update pre-existing language included within the paragraph that immediately follows the above referenced Chapter IV, Section 7.4 excerpt in which the agency introduced the new "04" "warning flag" which presently reads as follows: "The establishment or assumption of ongoing responsibility for medicals can take place at various times during a claim review. The actual date of when the RRE assumed ORM is not collected as part of the claim report. RREs will not receive a warning flag regarding possible late submission of a 'Y' value for the ORM Indicator (Field 78 on the Claim Input File Detail Record). However, CMS does reserve the right to audit an RRE and/or their agent(s) with respect to this issue (or any other Section 111 reporting issue). The RRE must have a record of when ongoing responsibility for medicals on a reported claim was assumed and was then terminated, and when such ongoing responsibility for medicals was reported to the BCRC under Section 111, in order to establish timely reporting."^[17]

Going forward, it will be interesting to see if CMS alters or removes the above passage given that it is contradictory to its introduction of the new "04" "warning flag" indicating that timeliness of an ORM report will be gauged based on the date of incident reported by the RRE.

Disposition code "03" description - clarifications

Finally, within the Summary pages for both Chapters IV and V, CMS notes that the "[t]he description of Response File disposition code 03 has been clarified (7.1)." The Summary page for Chapter IV indicates changes to Section 7.1 while the Summary page for Chapter V indicates changes to Appendix G.^[18]

In a nutshell, CMS has removed the existing phrase "error free" in relation to its discussion of the '03' disposition code in Chapter IV (Section 7.1) and Chapter V (Appendix G) outlined as follows:

Chapter IV, Section 7.1 Updates

The prior language within Section 7.1 of Chapter IV had read as follows: "Records returned with a '03' disposition code were found to be error-free, and the injured party submitted was matched to a Medicare beneficiary, but the Medicare coverage dates for the beneficiary are outside the time frame that is between the date of incident, and TPOC Date or the date ORM ended, as applicable." (authors' emphasis)^[19]

CMS's newly updated Section 7.1 simply removed the bold underlined text within the passage above and now reads as follows: "The injured party submitted was matched to a Medicare beneficiary, but the Medicare coverage dates for the beneficiary are outside the time frame that is between the date of incident, and TPOC Date or the date ORM ended, as applicable."^[20]

Chapter V, Appendix G Updates

Similarly, the prior language within Appendix G of Chapter V had read as follows: "Record was found to be error-free, and the injured party was matched to a Medicare beneficiary, but the period of time reflected on the claim report did not overlap the beneficiary's Medicare coverage dates." (authors' emphasis)^[21]

CMS's newly updated Appendix G simply removed the bold underlined text within the passage above and now reads as follows: "The injured party was matched to a Medicare beneficiary, but the period of time reflected on the claim report did not overlap the beneficiary's Medicare coverage dates."^[22]

Author's comments:

As noted above, from a textual standpoint, CMS has removed any reference to "error free" reporting in relation to the receipt of an "03" disposition code. While CMS did not provide any reasoning behind why the "error free" verbiage was removed, from a practical standpoint, based on the authors' understanding of how CMS's file processing is facilitated, the removal of this verbiage could possibly signal that CMS may intend to compare the timeframe of coverage being reported by an RRE with the associated Medicare beneficiary's Medicare entitlement period, thereby generating an "03" disposition when there is no overlap between the two, before any checks for errors are performed via their process. In other words, assuming the authors' speculation is correct, CMS would appear to return an "03" non-overlapping coverage disposition code without first checking the RRE's report for errors and, hence, this then "clarifies" the description of this disposition code accordingly.

Questions?Of course, do not hesitate to contact us if you have any questions regarding the above, or to learn more about how Verisk can help you with Section 111 reporting and related compliance issues.

[1] CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter I, Summary of Version 7.7 Updates page (p.1-1).

[2] CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter II, Summary of Version 7.7 Updates page (p.1-1). The Summary page states: "The table describing system-generated emails has been updated to include information for the RRE ID Notification email that is sent once a user completes the initial registration function and the Successful Registration PIN email that is sent once vetting is successful on the Section 111 COB Secure Website (COBSW) (Table 6-4)."

[3]CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter IV, Summary of Version 7.7 Updates page (p.1-1). CMS notes this change as follow in Chapter IV: "The table describing system-generated emails has been updated to include information for the RRE ID Notification email that is sent once a user completes the initial registration function and the Successful Registration PIN email that is sent once vetting is successful on the Section 111 COB Secure Website (COBSW) (Table 12-1).

[4]CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter I, Section 7, Table 7-1; See also, CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter II, Section 6, Table 6-4; See also, CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter IV, Section 12, Table 12-1.

[5]CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter I, Section 7, Table 7-1; See also, CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter II, Section 6, Table 6-4; See also, CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter IV, Section 12, Table 12-1.

[6]See generally, CMS's Section 111 COB Secure Website (COBSW) User Guide (Version 10.8, October 7, 2024), Chapter 4 and CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter II.

[7]Id.

[8]CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter III, Summary of Version 7.7 Updates page (p.1-1).

[9]CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter III, Section 6.5.1.4.

[10] CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter IV, Summary of Version 7.7 Updates page (p.1-1).

[11]CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter V, Summary of Version 7.7 Updates page (p.1-1). CMS states: "For NGHP claim files, a new "04" warning flag will be applied to claim response files with open ORM records when the later date of either the CMS Date of Incident on the claim record or the Part A Add Date is greater than 135 calendar days from the Start Date of the RRE's submission period. Additionally, compliance flag fields have been renamed warning flag (Appendix C and Appendix G)." Id.

[12]CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter IV, Section 7.4.

[13]CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter V, Appendix G, Table G-2.

[14]Fed. Reg. Vol. 88, No. 195, at 70370 (October 11, 2023).

[15]See, CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter IV, Section 7.4. See also, CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter V, Appendix G, Table G-2.

[16]CMS's Section 111 CMPs webinar, January 18. 2024.

[17] CMS's Section 111 NGHP User Guide (Version 7.6, July 1, 2024), Chapter IV, Section 7.4.

[18]See, CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter IV, Summary of Version 7.7 Updates page (p.1-1). See also, CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter V, Summary of Version 7.7 Updates page (p.1-1).

[19] CMS's Section 111 NGHP User Guide (Version 7.6, July 1, 2024), Chapter IV, Section 7.1.

[20]CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter IV, Section 7.1.

[21]CMS's Section 111 NGHP User Guide (Version 7.6, July 1, 2024), Chapter V, Appendix G, Table G-2.

[22] CMS's Section 111 NGHP User Guide (Version 7.7, October 7, 2024), Chapter V, Appendix G, Table G-2.

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