On Thursday November 12^th the Centers for Medicare & Medicaid Services (CMS) released an alert and an updated Section 111 NGHP User Guide to improve data quality efficiencies for Section 111 reporting services. The updates will convert some data validation errors into “soft edits,” allowing the claims record to be processed despite minor data quality issues. The announced changes will go into effect on April 4, 2021. The changes are as follows:

1. The “SP 31” response will convert to an “03” disposition code whenever a claim is reported. The “03” code is returned whenever the “Record was found to be error-free and the injured party was matched to a Medicare beneficiary, but the period of time reflected on the claim report did not overlap the beneficiary’s Medicare coverage dates.”  If an RRE receives an “03” code, then the RRE should re-report any claim where the ongoing responsibility for medicals (ORM) indicator is set to “Y.”  If ORM is not present on a claim, then no additional report is required following an “03” disposition code.

2. CMS is converting a number of “error codes” into “soft edits” that will not result in the rejection of a record but should be corrected by the RRE on their next quarterly file submission. These “soft edits” will apply to dozens of non-essential data quality errors that can cause a record to be rejected.  Some examples include claimant’s phone number and claimant representative information and many others.  As of April 2021 these data elements will not result in a rejection of the claim.  This is fantastic news, because the impacted data elements do not materially impact the data record, and CMS simply suggests that the record be corrected and resubmitted with clean data.  A full list of impacted error codes is available in the alert.

3. A new error code of CP13 will be added to Section 111 NGHP Response file processing. A CP13 code will be returned whenever a no fault policy limit of less than $1,000 is submitted.  For example, this is the code that would be submitted if the no fault policy limit is left blank.  This new error code will not delay processing, but it will require the RRE to resubmit the record with the proper no fault policy limit.

As a default, ECS’s MIR Service Section 111 reporting platform transmits only claims data that will allow the record to be processed.  Individual claim records will be withheld from reporting if CMS’ edits will reject the claim.  These changes, which will implement “soft edits” on a number of inconsequential data fields, will ensure that claims will not be withheld from processing simply due to a minor data anomaly.

The wonderful news is that this will make reporting easier for almost everyone, and should have no material impact to any company presently reporting data to Medicare.  Section 111 reporting will now be slightly less onerous.  For companies using a reporting agent such as ExamWorks Compliance Solutions, no additional development is anticipated.

It appears clear that Medicare is making these updates with an eye to the release of final Section 111 civil monetary penalty regulations.  As we have outlined numerous times this year, CMS proposes to penalize companies for late reporting, error-prone reporting, and reporting that is later contradicted by Medicare conditional payment disputes or appeals.  The proposed updates will not only reduce the frequency of data processing “errors,” but also allow Medicare to timely process claims data.  Timely reporting with fewer errors should allow Medicare to focus penalty enforcement on truly bad actors, reducing the possibility that excusable neglect could lead to potentially existential risk.

We applaud CMS for making these changes, which will lead to more accurate, timely, and complete reporting.  ECS will continue to closely monitor any Section 111 reporting changes and outline the critical context of those reporting changes to your company.  Contact us today to learn more about how these changes may impact your claims process, or to learn more about our tailored Section 111 reporting solutions. Our Mandatory Insurer Reporting Team can be reached at MIRService.Support@examworkscompliance.com or 678-222-5454 to schedule an evaluation today.