Section 111 Reporting User Guide and Civil Money Penalties Webinar Highlights

Stay up-to-date with the latest CMS developments!  This month, we’re covering the release of the NGHP Section 111 Reporting User Guide Version 7.7, the annual update to the ICD exclusion list, and key insights from the CMS Section 111 Civil Money Penalties webinar.

NGHP User Guide Version 7.7 Released

On October 7, 2024, CMS published Version 7.7 of the NGHP (Non-Group Health Plan) Section 111 Reporting User Guide.  Here are notable updates:

Reporting of Wrongful Death Claims

In Chapter III; Policy Guidance, Section 6.5.1.4, CMS provided the following clarification:

“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.”

This statement is consistent with CMS’s previous guidance that Total Payment Obligation to Claimant (TPOC) amounts are reported only when medicals are claimed and/or released, or the settlement has the effect of releasing medicals.

Compliance Flags are now Warning Flags

In Chapter IV: Technical Information, CMS has renamed “Compliance Flags” in Section 7.4 to “Warning Flags.” Additionally, a new “04” warning flag has been introduced. This flag applies to claim response files with open Ongoing Responsibility for Medicals (ORM) records when the later date of either the CMS Date of Incident or the Part A Add Date is more than 135 calendar days after the Start Date of the Responsible Reporting Entity’s (RRE’s) submission period.

Understanding Warning Flags and Penalties

It’s important to note that warning flags do not necessarily equate to a potential civil monetary penalty for late Section 111 reporting.  Here’s the key difference:

• Warning Flags: Triggered if ORM or TPOC is reported more than 135 days after it should have been reported, as defined in the user guide.
• Penalties: Potential penalties don’t come into play until 365 days have passed since the date the information should have been reported.

Why the different timeframes?  We assume it is to encourage RREs to report promptly, ensuring CMS has the necessary information to coordinate benefits properly.  Warning flags act as a reminder to the RRE that repeated reporting delays could lead to more significant issues, including potential penalties.

Updated ICD Code Excluded List

CMS published its annual update of valid and excluded liability and no-fault ICD-9 and ICD-10 codes for Section 111 reporting purposes. The list can be found here.

CMS Webinar Highlights: Section 111 Civil Money Penalties

On October 17, 2024, CMS hosted a webinar on Section 111 Civil Money Penalties.  The webinar slides can be found here.  Key takeaways:

• Civil Money Penalty Correspondence: Notices will be mailed to the RRE’s Authorized Representative and the Account Manager.  Reporting agents, such as Tower MSA Partners, will not receive a copy of the notice.  Therefore, it is important for the RRE to ensure address information is up-to-date.

• Compliance Clock Started: The compliance clock began ticking on October 11, 2024.  Eligible MSP occurrences occurring on or after this date must be reported within 365 days.

• Obtaining Beneficiary Information: When trying to gather beneficiary details, such as a Social Security Number, the RRE must reach out to both the beneficiary and, if applicable, their attorney. Contacting only the attorney isn’t sufficient. Additionally, you must make at least three attempts to obtain the information, with at least two attempts made via mail or email.

If you have any questions about these updates, please contact Tower’s Chief Compliance Officer, Dan Anders, at daniel.anders@towermsa.com.