CMS Update: Section 111 NGHP User Guide

On July 13, 2015, CMS issued an updated Section 111 NGHP User Guide. In an effort to prevent false positives in partial SSN searches, CMS increased the number of additional criteria needed to return a match. When submitting a beneficiary using a partial SSN of five digits, all four of the remaining criteria- first initial, surname, date of birth, and gender- must now be matched exactly.

Additionally, the new User Guide replaces the term “TPA” with “recovery agent” and provides dedicated fields for RREs to submit recovery agent information on the TIN reference file. The Section 111 URL was also changed to https://www.cob.cms.hhs.gov/Section111/LoginWarning.action.

The current User Guide is available here.

Alert: CMS Issues Updated Section 111 NGHP User Guide

On February 2, 2015, CMS issued an updated Section 111 NGHP User Guide incorporating the following language from the August 19, 2014, Alert addressing liability cases involving exposure, ingestion, or implantation and December 5, 1980:

Any operative amended complaint (or comparable supplemental pleading) must occur prior to the date of settlement, judgment, award, or other payment and must not have the effect of improperly shifting the burden to Medicare by amending the prior complaint(s) to remove any claim for medical damages, care, items and/or services, etc.

Where a complaint is amended by Court Order and that Order limits Medicare’s recovery claim based on the criteria contained in this alert, CMS will defer to the Order. CMS will not defer to Orders that contradict governing MSP policy, law, or regulation.

The August 19, 2014, Alert also provides that Medicare will assert a recovery claim if "[e]xposure, ingestion, or the alleged effects of an implant on or after December 5, 1980, is claimed, released, or effectively released in the most recently amended operative complaint or comparable supplemental pleading" (emphasis added).  In addition, the Alert states that one of the conditions that must be met for Medicare to not assert a recovery claim is that "[e]xposure, ingestion, or an implant on or after December 5, 1980, has not been claimed in the most recently amended operative complaint (or comparable supplemental pleading) and/or specifically released" (emphasis added).

The new CMS User Guide does not include the underlined language above.  However, we have contacted CMS and confirmed that this language was left out inadvertently and the August 19, 2014, alert is still in effect.  We expect to see a new User Guide issued in the near future including the underlined language above and we will let you know when it has been issued.

The current User Guide is available here.

CMS Issues Updated Section 111 NGHP User Guide

On January 5, 2015, CMS issued an updated Section 111 NGHP User Guide (version 4.4).  The new User Guide incorporates the previous Alerts on reporting partial SSNs.  As we discussed in previous posts, 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 new User Guide was also updated to show that for liability claims not involving ORM, RREs will receive the CJ07 error code for reporting liability TPOCs with TPOC dates on or after October 1, 2014, with a cumulative TPOC amount less than or equal to the current $1,000.00 threshold.  Previously, RREs could optionally report below-threshold liability TPOCs with TPOC dates on or after October 1, 2014, if the cumulative TPOC amount was more than $300.00.  CMS also included new tables in the section in the User Guide on the liability TPOC threshold (section 6.4.3).  The new Table 6-5 shows liability TPOC reporting requirement for TPOC dates since October 1, 2011, along with information on optional reporting for below-threshold liability TPOCs with TPOC dates prior to October 1, 2014.  The new Table 6-6 shows when RREs will receive the CJ07 error code for reporting below-threshold liability TPOCs.

December 10, 2014 alert can be found here.
* Updated to include the link to the current NGHP User Guide, found here.