The Centers for Medicare and Medicaid Services (CMS) has begun the new year with some updates to its MMSEA Section 111 NGHP User Guide.  This guide provides everything and anything you ever wanted to know about mandatory insurer reporting by non-group health plans.  Version 6.2 provides the following updates:
 
$750 Reporting Threshold
 
In follow-up to its November 2020 announcement that it will be maintaining the $750 TPOC threshold for reporting and Medicare conditional payment recovery, CMS states:
 
As of January 1, 2021, the threshold for physical trauma-based liability insurance settlements will remain at $750. CMS will maintain the $750 threshold for no-fault insurance and workers’ compensation settlements, where the no-fault insurer or workers’ compensation entity does not otherwise have ongoing responsibility for medicals (Sections 6.4.2, 6.4.3, and 6.4.4).
 
Key takeaway:  Maintaining the $750 threshold means there are no changes to the reporting processes, determinations of claims that should be reported, or when conditional payments should be investigated or resolved.
 
Reporting Future ORM Termination Date
 
Per CMS:
 
To address situations where Responsible Report Entities (RREs) can identify future ORM termination dates based on terms of the insurance contract, RREs can now enter a future Ongoing Responsibility for Medicals (ORM) Termination Date (Field 79) up to 75 years from the current date (Section 6.7.1)
 
Key takeaway:  A future ORM termination date can only be submitted if it is certain, e.g., the date is specified in an insurance contract or a statutory limitation provides for its exact determination. The prior policy only allowed the reporting of an ORM termination date that was six months into the future.  The expansion to 75 years should allow for most date certain ORM terminations to be reported.
 
Data Exchange Update
 
Per CMS:
 
As part of CMS’ commitment to the modernization of the Coordination of Benefits & Recovery (COB&R) operating environment, changes are being implemented to move certain electronic file transfer data exchanges to the CMS Enterprise File Transfer (EFT) protocol. As part of this change the exchange of data with the COB&R program via Connect:Direct to GHINY SNODE will be discontinued. The final cutover is targeted to occur in April 2021. File naming conventions and other references have been updated in this guide. Contact your EDI Representative for details (Sections 10.2 and 10.3).
 
Key takeaway:  Right now, CMS offers four methods of data transmission that Section 111 RREs or their reporting agents can use to submit and receive electronic files.  CMS is discontinuing the Connect:Direct method, and since Tower does not communicate with CMS via this method there will be no impact to our reporting processes.
 
Policy Number Now a Key Field
 
Per CMS:
 
To support previous system changes, Policy Number (Field 54) has been added as a key field. If this field changes, RREs must submit a delete Claim Input File record that matches the previously accepted add record, followed by a new add record with the changed information (i.e., delete/add process) (Sections 6.1.2, 6.6.1, 6.6.2, and 6.6.4).
 
Key takeaway:  Previously, if a claim input file was updated with a different policy number for the same claim it would create two records with the BCRC.  This could duplicate Medicare conditional payment recovery efforts.  CMS’s solution is to have the RRE delete the prior record with the old policy number and add a new record with the new policy number.
 
Retraction of Soft Code Error
 
Per CMS:
 
In Version 6.1, we announced that several input errors will become “soft” errors starting April 5, 2021. However, CP03 will not become a soft edit. The Office Code/Site ID (Field 53), which triggers CP03, is used to identify correspondence addresses, and if incorrect, could result in mail being sent to the wrong place. Therefore this error will continue to reject the record (Appendix F).
 
Key Takeaway:  An error in Office Code/Site ID (Field 53) will not be considered a soft edit and will result in file rejection. An earlier Tower article, November CMS Mandatory Reporting and Conditional Payment Updates, explained these so-called “soft” code errors.
 
If you have any questions on these updates to the Section 111 User Guide, please reach out to Tower’s Chief Compliance Officer, Dan Anders, at daniel.anders@towermsa.com or 888.331.4941.