Updated NGHP User Guide Version 6.2 Issued: $750 TPOC Threshold Confirmed for GL, WC, and NF

The Non-Group Health Plan (NGHP) User Guide is the primary source for Section 111 reporting requirements as mandated by Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA). As the Centers for Medicare & Medicaid Services (CMS) does periodically, necessary updates are made to the Guide notifying Responsible Reporting Entities (RREs) of such changes in reporting requirements.

42 U.S.C. § 1395y(b)(8) provides that the “applicable plan” is the RRE and defines “applicable plan” as follows: “APPLICABLE PLAN—In this paragraph, the term “applicable plan” means the following laws, plans, or other arrangements, including the fiduciary or administrator for such law, plan, or arrangement: Liability insurance (including self-insurance), No-fault insurance, and Workers' compensation laws or plans.”

For those not in the MSP world with regularity, MMSEA Section 111 reporting is often associated with perhaps carrying the most offensive penalty for RREs deemed noncompliant under the Medicare Secondary Payer Act (MSP): a potential of up to $1000 per day/per claim Civil Monetary Penalties (CMPs) for noncompliance/failure to report. A recent NPRM with comment period closing in April 2020 on this issue is in the hotseat for this year to finalize parameters around CMP issuance as discussed in our recent blog.

Accordingly, it is imperative that RREs stay up to date on any changes to the User Guide to avoid CMPs. The four (4) updates in NGHP User Guide Version 6.2 are listed as the following:

• To address situations where Responsible Report Entities (RREs) can identify future ORM termination dates based on terms of the insurance contact, 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).
• 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).
• 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 responsibly for medicals (Sections 6.4.2, 6.4.3, and 6.4.4).
• 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).

Commentary: The $750 threshold for workers’ compensation, general liability, and no-fault claims is not a surprise as it was announced via an Alert last year and the threshold has remained the same for the last 4-5 years.

However, the ORM update allowing RREs the ability to terminate Ongoing Responsibility for Medicals (ORM) up to 75 years from the current date is interesting and worthwhile of a discussion. Noteworthy of an updated Section 6.7.1 of the Guide provides the following:

With respect to ORM, a determination that a case is “closed” or otherwise inactive does not automatically equate to a report terminating the ORM. If the ORM is subject to reopening or otherwise subject to a further request for payment, the record submitted for ORM should remain open. (Medicare beneficiaries have a continuing obligation to apply for all no-fault or workers’ compensation benefits to which they are entitled.) Similarly, if a file would otherwise be “closed” due to a “return to work” and no additional anticipated medicals, a report terminating the ORM should not be submitted as long as the ORM is subject to reopening or otherwise subject to an additional request for payment. For certain states which require a workers’ compensation or no-fault claim be left open for medicals indefinitely, this second type of report may never be submitted. In addition, RREs are not to submit an expected, anticipated, or contingent ORM Termination Date. ORM Termination Dates should only be submitted when the termination of ORM is certain. Future-dated ORM Termination Dates can be dated no more than 75 years from the current date.

In essence, the insurance contract must have a known date wherein medical coverage would no longer be covered for the Medicare beneficiary to utilize this new allowed method of ORM termination, which may be limited in its applicability for RREs. As indicated by CMS, lifetime medical states cannot avail themselves of this 75-year exception, and neither can administratively closed claims. Nonetheless, any broadening of the ability for RREs to terminate ORM is welcomed as the current standards are stringent.

To terminate ORM, one of the following must occur: 1) The medical benefits to the claimant have exhausted under state law; 2) The treating doctor has provided a letter that future medical treatment related to the case has completed; or 3) The case has settled, and the carrier has terminated its responsibility to fund future medical as part of that treatment. 

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