CMS Update: Section 111 Reporting Issues

On December 10, 2014, CMS held an NGHP telephone conference to address issues with Section 111 reporting.

In the first part of the call CMS went over recent alerts that have been issued regarding the use of partial Social Security Numbers for the query process, the reporting of Recovery Agent information, and changes in how CMS names its Section 111 response files.  As we previously reported, on September 10, 2014, CMS issued an Alert providing that, beginning January 5, 2015, where a NGHP RRE cannot obtain an individual’s HICN or full SSN, the RRE may report the following data elements that will enable CMS to properly identify a Medicare beneficiary:

•Last five digits of SSN
•First Initial
•Surname
•Date of Birth
•Gender

*The September 10, 2014, Alert is available for download here. 

*CMS issued a follow-up Alert on November 25, 2014, providing technical guidance on partial SSN submissions. This Alert is available for download here.

As discussed in the call, on November 10, 2014, CMS issued an Alert on reporting Recovery Agent information under Section 111.  This Alert provides that beginning July 13, 2015, for RREs that have a separate agent that assists with tasks related to MSP recovery demands, RREs may provide CMS with information about the agent in fields 16 through 22 on the TIN reference file.  This process will replace the current process for RREs to submit TPA information on the TIN reference file.  If an RRE provides CMS with Recovery Agent information on the TIN reference file, both the RRE and the Recovery Agent will receive any recovery correspondence sent as a result of information reported under Section 111.

*The November 10, 2014, Alert is available for download here.

As CMS also discussed, CMS issued an Alert on October 27, 2014, providing that beginning April 6, 2015, the naming convention for Section 111 response files will be modified to ensure that all response file names are unique.

*The October 27, 2014, Alert is available for download here.

CMS said that an updated NGHP User Guide incorporating these changes would be issued in January 2015.

CMS confirmed in the question and answer session that RREs would be unable to test query submission files with partial SSNs prior to January 5, 2015.  CMS also stated that RREs that prefer to query with full SSNs may continue to use the prior model language on collection of HICNs and SSNs that does not address the option of providing a partial SSN, even though the prior model language is no longer available on the CMS website.

CMS also answered questions related to loss of consortium claims.  CMS confirmed that if a Release specifically releases an RRE from a loss of consortium claim, the settlement would reportable under Section 111 even if state law specifically does not allow a claimant to assert a loss of consortium claim.  CMS indicated that the same applies to any type of claim that cannot be legally asserted.  If a claim is specifically released, the fact that it could not have been legally asserted does not make it not reportable.  CMS said that they are still considering an Alert providing guidance on loss of consortium claims, though CMS gave no time frame for providing the Alert.

In addition, CMS addressed questions related to short term travel, hospital confinement, and accident only policies.  CMS indicated that an accidental death benefit paid under an accident policy would not need to be reported since it is paid without regard to medical expenses being incurred.  CMS did say, however, that payments made under a hospital confinement policy would be reportable, even though the payments would not be made specifically for medical expenses and are payable in a set amount.  This information is consistent with the statement in the User Guide that “Accident & Health, Short Term Travel and Occupational Accident Products are considered no-fault insurance by CMS and reportable as such under Section 111.”  It is interesting to note, however, that the following definition of no-fault insurance under 42 CFR 411.50(b) is more narrow: “No-fault insurance means insurance that pays for medical expenses for injuries sustained on the property or premises of the insured, or in the use, occupancy, or operation of an automobile, regardless of who may have been responsible for causing the accident.  This insurance includes but is not limited to automobile, homeowners, and commercial plans. It is sometimes called ‘medical payments coverage’, ‘personal injury protection’, or ‘medical expense coverage’.” The types of policies at issue do not specifically pay for injuries sustained on the property of the insured or in the use of an automobile, though they obviously could.

We will continue to provide you with all additional updates as they are released.