On Thursday, January 21, 2021 the Centers for Medicare & Medicaid Services (CMS) released an updated Section 111 NGHP User Guide (back-dated to January 11, 2021). While it contained nothing earth-shattering, there are a few important updates of note.

1. CMS will now accept a claim with an ORM Termination Date that is up to 75 years in the future. This is a beneficial evolutionary aspect of Section 111 reporting in that it eases the burden of claims administration to some extent, allowing the industry to report a future ORM Termination Date where policy limits or state statute may apply.  For those of you that are Section 111 history buffs, you may recall that initially CMS would only accept an ORM Termination Date that was up to 30 days in the future.  Then a short time later, CMS began accepting an ORM Termination Date that was up to 6 months in the future.  Here at ECS, our system accommodated future ORM Termination Dates, but with this change at CMS, we will remove that logic immediately.

2. The Policy Number field is now considered a Key Field and must be treated as such. CMS defines fields as being key, important or standard.  Key fields are those used by CMS to uniquely identify a claim over time.  When the value in a key field changes, the prior accepted version of the claim must be sent as a Delete record, and then the claim with the new value is to be sent as an Add record.  Because Policy Number had not been defined as a key field, resubmitting the same claim with a different Policy Number resulted in CMS maintaining two versions of a claim, which then caused downstream issues when it came to Conditional Payment recovery activities.  To accommodate this change, we will immediately modify the reporting logic to identify a change in Policy Number and automatically submit the requisite Delete/Add record combination, as it already does for the other key fields.  (To finish the thought on field types, when a change in an important field occurs, a single Update record should be submitted to CMS; and no subsequent records need to be submitted to CMS for changes to standard fields.  The logic in our system automatically recognizes changes to important fields and submits the Update record.)

3. The November Alert regarding “soft” errors has been updated to indicate that CP03 (problem with the Office Code/Site ID field) will not become a soft error on April 5, 2021. This retraction makes perfect sense, as the Office Code/Site ID field links a claim to the appropriate TIN record so that CMS knows where to direct recovery correspondence.  Fortunately, this change will have absolutely no impact to our clients because we populate this field with our own values when reporting claims to CMS.  Therefore, you should rarely, if ever, receive the CP03 error from CMS.

The updated NGHP User Guide also references a plan to discontinue supporting the Connect:Direct protocol for exchange files, as CMS updates their infrastructure.  This may apply to some in the industry, but the majority of companies and vendors utilize Secure File Transfer Protocol (SFTP) to exchange files with CMS.

And finally, the updated NGHP User Guide reiterates the already established $750 TPOC Threshold for no-fault, workers’ compensation and physical trauma-based liability settlements.  Recall that there is no threshold for liability claims involving ingestion, exposure or implantation.

ECS will continue to closely monitor any Section 111 reporting changes and outline the critical context of those reporting changes to you.  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.