The Centers for Medicare and Medicaid Services (CMS) issued a series of updates over the past month, which include an updated NGHP Section 111 User Guide, the latest Top 10 Section 111 Reporting errors, and its 2024 conditional payment recovery threshold.  We have summarized these for you below.

Updated NGHP Section 111 User Guide

CMS released NGHP User Guide Version 7.4, which incorporates the Section 111 civil monetary penalties rule into Section 5.1 of Chapter III: Policy Guidance of the guide. See our most recent update on Section 111 penalties in Recap of CMS Section Penalties Webinar.  CMS includes the following in the guide:

The occurrences to be audited will include both Section 111 submissions and records from sources outside of the Section 111 reporting process, to ensure that CMS does not miss those situations where an RRE has entirely failed to report the occurrence. RREs will only be informed when there is a potential instance of non-compliance.

In short, CMS will be auditing untimely reporting through Section 111 and reviewing reports outside of Section 111 to determine if there was a failure to report at all.

Top 10 List of Section 111 Reporting Errors

CMS released a chart of the Top 10 Section 111 Non-Group Health Plan Reporting Error Codes from 7/1/2023 to 12/15/2023.  The top three reporting errors were:

• TN – 99: No matching, valid TIN Reference File Detail Record was found for the TIN/Office Code combination on the Claim Input File Detail Record.
• CI05 – Invalid Diagnosis Code 1.
• SP49 – No previously accepted record can be matched to the submitted delete. Delete failed.

These issues are what CMS calls “hard errors,” meaning the record will be rejected.  Remember that if a record is rejected and not timely corrected, it could be subject to Section 111 civil monetary penalties for untimely reporting.

$750 Threshold Kept for Reporting and Conditional Payment Recovery

In a February 14, 2024 alert, CMS announced that the 2024 conditional payment recovery threshold for liability, no-fault and workers’ compensation settlements will remain at $750. Accordingly, Total Payment Obligations to the Claimant (TPOCs) in the amount of $750 or less do not need to be reported to CMS through the Section 111 Mandatory Reporting process. Nor will CMS attempt to recover conditional payments for TPOCs of $750 or less (The threshold does not apply to liability settlements for alleged ingestion, implantation or exposure cases.)

By way of background, pursuant to the SMART Act of 2012, CMS must determine a threshold amount each year to ensure the collection cost stays within the amount recovered through such efforts.

Please get in touch with Tower’s Chief Compliance Officer, Dan Anders, with any questions at (888) 331-4941 or daniel.anders@towermsa.com