Updated CMS Reference and User Guides Reveal Minor Changes

October 18, 2018

CMS User Guides for Section 111 Reporting. open book with colored page markers

On 10/1/2018, the Centers for Medicare and Medicaid Services (CMS) released updates to the Workers’ Compensation Medicare Set-Aside (WCMSA) Reference Guide, the Medicare Secondary Payer Recovery Portal (MSPRP) User Guide and the MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting NGHP User Guide. These updates to the reference guide and user guides are all fairly minor, having minimal to moderate impact on the associated CMS MSP processes. A summary of the updates is provided below.

WCMSA Reference Guide

The WCMSA Reference Guide provides for most CMS policies pertaining to the review and approval of MSAs. Version 2.8 of the guide provides as follows:

HICN Replaced with MBI: As CMS explains:

As required by Section 501 of the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015, CMS must discontinue all Social Security Number (SSN)-based Medicare identifiers and distribute a new 11-byte Medicare Beneficiary Identifier (MBI)-based card to each Medicare beneficiary by April 2019. All fields formerly labeled as “HICN” have been relabeled as “Medicare ID” and can accept either a HICN or the new MBI.

Updated CDC Life Expectancy Table Link: While with this Reference Guide update CMS is not presently changing the CDC Life Expectancy Table used for calculating life expectancy in the MSA, CMS is updating the link which was outdated.

Revised Tables Pertaining to Verifying Jurisdiction and Calculation Method: In states where the fee schedule provides for regional adjustments, for example, New York, the Reference Guide lists criteria for determining the correct fee schedule rates to use in the MSA. CMS added an additional level of criteria and revised the table (9-1) that provides what is called an “Order of Precedence” in determining the zip code to utilize for pricing. CMS also added a table (9-2) clarifying pricing rules when claims are filed with U.S. Department of Labor Office of Workers’ Compensation Programs and states where no fee schedule is applicable.

MSPRP User Guide

The MSPRP is a web-based portal providing online access for attorneys, Medicare beneficiaries, insurers and authorized representatives to Medicare conditional payment information, the ability to dispute and/or appeal conditional payments and initiate the Demand Letter process among other tasks. Version 4.3 of the User Guide includes the addition of two new columns to the Case Results page providing for Case Status and Contractor, news fields which provide more relevant and updated information for claims awaiting response from the BCRC and three new warning pages to ensure information related to submitting redetermination, compromise or waiver requests is complete.

A notable improvement comes with the submission of Letters of Authority or Proofs of Representation allowing for third-party representatives, such as Tower MSA Partners, to act on behalf of insurers and Medicare beneficiaries. The process has been once a Proof of Representation or Letter of Authority is submitted through the portal the submitter would be required to wait a few days for the authorization to be authenticated. Updates to the MSPRP now allow authorizations to be uploaded to the portal with immediate authentication. As a result, the cuts down on the time to obtain Medicare conditional payment information.

Section 111 NGHP User Guide

CMS released Version 5.4 of the NGHP User Guide, which provides both policy and technical updates for the Section 111 Mandatory Insurer Reporting process. Notable updates are as follows:

  • As a result of Angel Pagan replacing Jeremy Farquhar as the EDI Department Director, new contact information is provided.
  • 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 zeros or a full policy number (Section 6.6.5). 
  • The excluded and no-fault excluded ICD-10 diagnosis codes have been updated for 2019 (Appendix I and Appendix J)

Practical Implications

We do not anticipate the changes to the WCMSA Reference Guide to have any impact on either increasing or decreasing allocations on CMS-approved MSAs. As noted above, the updates to the MSPRP authorization authentication process will improve the turnaround time for obtaining conditional payment information. Finally, the Section 111 User Guide updates are all minor in nature and have minimal impact on the reporting processes.

If you have any questions regarding these updates, please contact Dan Anders at (888) 331-4942 or Daniel.anders@towermsa.com.