Tag: ORM Termination

CMS Section 111 Update: Key Changes to ORM Termination and TPOC Reporting

May 13, 2026

The Centers for Medicare and Medicaid Services (CMS) has released an update to the Section 111 NGHP User Guide (Version 8.4), introducing important clarifications related to:

  • Ongoing Responsibility for Medicals (ORM)
  • Total Payment Obligation to Claimant (TPOC) reporting
  • Wrongful death claims
  • Medicare Set-Aside (MSA) reporting in multi-defendant cases.

While many of these updates reinforce existing practices, several changes carry meaningful compliance implications for Responsible Reporting Entities (RREs).

Expanded Guidance on ORM Termination

CMS updated Chapter III, Section 6.3.2 of the Policy User Guide to clarify acceptable circumstances for terminating ORM.

The revised language states:

“Where the insurer’s responsibility for ORM has been terminated per the terms of the pertinent insurance contract, such as maximum coverage benefits, or any other reason that is not prohibited by the terms of the insurance contract or applicable state or federal law.”

CMS also added:

“Note: An insurer’s refusal to accept ORM, or to continue to accept ORM, is a valid ORM termination reason, provided that the refusal is permitted by applicable state or federal law and the terms of the insurance contract.”

What This Means

This update introduces helpful flexibility, but it does not create new substantive grounds for terminating ORM. Nonetheless, RREs may feel more comfortable with terminating ORM based on the following:

  • Claim denials
  • Independent Medical Examination (IME) results
  • Maximum Medical Improvement (MMI) determinations
  • Claimant non-compliance (e.g., refusal of treatment or IME)

In short, CMS has clarified when termination may be recognized, not expanded the legal basis for termination.

Clarification of TPOC Date in Workers’ Compensation Settlements

CMS also added a helpful example in Section 6.4 of the Policy Guide regarding the proper TPOC date to use when commission approval of a workers’ compensation case is required:

“Example: The parties to a workers’ compensation case execute an agreement regarding the claim on 01/20/2026. The state requires the workers’ compensation commission to approve the final settlement details and said approval occurs on 02/05/2026.”

According to CMS, the TPOC date is February 5, 2026, because it was the later of:

  • The date the agreement was fully executed
  • The date the court or commission approved the agreement.

What This Means

For many workers’ compensation settlements, this confirms what has already been standard industry practice: the commission approval date will be the TPOC date.

Updated Approach to Wrongful Death Claims

CMS also modified the language in Section 6.5.1.4 related to wrongful death claims.

Previously, CMS stated that wrongful death settlements were not reportable if they:

  • Did not claim or release medicals, and
  • Did not have the effect of releasing medicals

The revised language now emphasizes Medicare recovery rights and documentation.

“Note: In order for the wrongful death theory of liability to preclude Medicare from recovering from a settlement, judgment, award, or other payment, complete documentation must be provided that shows what was claimed and released or had the effect of being released. Additionally, a citation to the appropriate state statute or case law that precludes recovery from a wrongful death settlement should be included with any such dispute or appeal.

The prior language was:

Settlements, judgments, awards, or other payments 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.

What This Means

It is unclear why CMS modified the language in this section, which shifts the focus from the release of medicals to recovery; however, the underlying requirements remain: a settlement is not reportable unless medicals are claimed and released as part of that settlement.  This includes a wrongful death settlement.

TPOC Reporting in Multi-Defendant Cases

CMS also clarified reporting requirements for multiple settlements involving the same claimant. The updated guidance confirms that where liability is proportionate or several, but not joint and several, each RRE should report only its own TPOC amount.

CMS added the language in bold:

Multiple settlements involving the same individual – If there will be multiple TPOCs submitted for the same individual, for the same incident, but reported by different RREs (proportionate or several liability but not joint and several), the records shall reflect each RRE’s unique TPOC amount and not the aggregate TPOC the beneficiary will be receiving. If more than one RRE has assumed responsibility for ongoing medicals, Medicare would be secondary to each such entity.

Example

If:

  • The total settlement is $100,000, and
  • One RRE’s share is $25,000

Then that RRE reports a TPOC amount of $25,000 — not the full settlement amount.

What This Means

This reinforces that reporting obligations where there is not joint and several liability are entity-specific, aligning each RRE’s reporting with its actual financial responsibility and avoiding over-reporting of settlement amounts.

The update helps avoid:

  • Over-reporting settlement amounts
  • Duplicate reporting
  • Confusion around proportional liability scenarios

Medicare Set-Aside (MSA) Reporting Clarifications

CMS also revised guidance regarding WCMSA reporting in cases involving:

  • Multiple dates of injury, or
  • Multiple defendants

CMS updated with new information in bold:

“As it relates to multiple dates of incident, an MSA, if applicable, shall be reported under the earliest date of incident, if only one TPOC is made. If multiple TPOCs are submitted, but only one MSA is reported, the MSA shall be reported on the first TPOC only. Where there are multiple defendants (RREs) reporting each RRE must report the total MSA Amount—not just its assigned or proportionate share. System logic exists such that only the first reported MSA amount will be applied for purposes of coordination of benefits.”

The updated language states that where multiple RREs are reporting, each RRE must report the full MSA amount — not merely its proportionate share.

CMS further notes that system logic applies only the first reported MSA amount for coordination of benefits purposes.

What This Means

This creates a notable distinction between:

  • Financial responsibility, and
  • Reporting obligations

Even where liability is divided, all RREs are required to report the entire MSA amount, making coordination among defendants critical to ensure consistency and avoid confusion.

Example (using the scenario above)

Assume:

  • Total settlement = $100,000
  • One RRE’s share = $25,000
  • WCMSA amount = $50,000

The RRE would report:

  • TPOC Amount: $25,000
  • WCMSA Amount: $50,000

Because all RREs must report the full MSA amount, coordination among defendants is critical to ensure consistency and avoid reporting discrepancies.

Final Thoughts

These updates do not fundamentally change Section 111 reporting—but they do tighten expectations around documentation, consistency, and defensibility.

RREs should review internal protocols, particularly around:

  • ORM termination decisions
  • Wrongful death claim handling
  • Coordination in multi-defendant settlements

Small missteps in these areas can create outsized compliance risk.

If you have any questions, please reach out to Tower’s Chief Compliance Officer, Dan Anders, at daniel.anders@towermsa.com .

 

CMS to Provide RREs with Response File on ORM Record Changes

January 11, 2023

book marked by sticky notes illustrating changes Section 111 reporting on ORM

Starting July 2023, Responsible Reporting Entities (RREs) can access updates/changes that another source has made to their claims for Ongoing Responsibility for Medicals (ORM).  The Centers for Medicare and Medicaid Services (CMS) announced this in an update to its MMSEA Section 111 NGHP User Guide, Version 7.0.

It may surprise insurers and self-insurers that the ORM data they report through Section 111 reporting can be modified by the Benefits Coordination and Recovery Center (BCRC), which coordinates benefits on behalf of CMS. For example, suppose a claimant contacts the BCRC and advises that they are being denied medical care due to an open ORM (ORM indicates the RRE accepts the claim). In that case, the BCRC may update the ORM record to indicate that medical has been terminated (especially if the claimant indicates the case has been settled).

The RRE needs to be notified of this action to correct its reporting or to advise the BCRC that this was an erroneous change to the record.

Presently, and in our experience, the BCRC typically issues a letter to the RRE advising of the change it made to the ORM status.  Starting this summer, RREs can also access these changes through Section 111 reporting. The revised user guide states:

Effective July 2023, RREs will be able to opt in via the Section 111 secure website to receive a monthly NGHP Unsolicited Response File. This will provide critical information about updates to ORM records originally submitted in the last 12 months and allow RREs to either update their internal data or contact the Benefits Coordination & Recovery Center (BCRC) for a correction.

This report will provide the source of the record modification and the reason for it. This should eliminate confusion when the BCRC changes ORM reporting data.

Other Updates to Section 111 User Guide

CMS included these other updates in Version 7.0 of the user guide:

  • Sections 6.4.2, 6.4.3 and 6.4.4. of Chapter III: Policy Guidance indicated CMS would maintain the $750 reporting threshold for physical trauma-based liability insurance settlements and 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.
  • In Chapter IV: Technical Information besides the aforementioned ability to, as of July 2023, obtain an NGHP Unsolicited Response File, CMS put in place the following changes:
  • Information on recovery agents was clarified to emphasize that such agents need written authorizations to pursue any post-demand actions (Section 6.3.1).
  • Recovery agents may now view the Open Debt Report on the Medicare Secondary Payer Recovery Portal (MSPRP), if the agent has an active MSPRP account with a TIN matching one submitted on the RRE’s TIN Reference File (Section 6.3.1.2).
  • ORM Termination Date field number 79 was corrected for the Event Table (Section 6.9.1).

As Tower is a recovery agent for many of our clients, the ability to download a copy of the Open Debt Report will be helpful in monitoring CMS’s ongoing recovery actions.

  • Finally, CMS updated Chapter V: Appendices as follows:
  • The CP13 soft edit policy limit amount has decreased from $1000 to $500 (Appendix F).
  • For the TIN Reference File, the Go Paperless Indicator is no longer required when submitting the Recovery Agent TIN (Field 25) (Appendix G).

If you have any questions on these updates, don’t hesitate to contact Tower’s Chief Compliance Officer, Dan Anders, at Daniel.anders@towermsa.com or 888.331.4941.