On January 9, 2023, the Centers for Medicare and Medicaid Services (CMS) published version 7.0 of the Non-Group Health Plan (NGHP) User Guide, found here. Version 7 contains a few policy and technical updates. We’ll dissect them one-by-one below.
Modification: As of July 2023, the following change will be made: To inform RREs when another source has updated their submitted records, RREs may now opt in via the Section 111 Coordination of Benefits Secure Website (COBSW) application to receive a monthly NGHP Unsolicited Response File. This will provide key information about updates to ORM records originally submitted in the last 12 months and allow RREs to either update their own internal data or contact the BCRC for a correction (Chapter 7).
Impact: This file will contain claims that were updated via manual channels such as the beneficiary contacting the BCRC call center. RREs will receive an indication that a claim has been updated, however based on the current file layout, there is no indication as to what was changed via the manual update.
Modification: As of January 1, 2022, 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).
Impact: None. The TPOC Threshold has remained at $750 for 6 years running.
Modification: The information on recovery agents has been clarified to emphasize that such agents need written authorizations to pursue any post-demand actions (Section 6.3.1).
Impact: None. Please recall that in the most recent CMS town hall meeting, which we blogged about here, CMS reminded RRE entities and their third party recovery agents (TPRAs) that there is no Letter of Authority (LOA) required for informal conditional payment disputes against RREs where the representative filing the dispute is listed in the TPRA field. Once a Demand is issued, however, any recovery agent acting to appeal on behalf of the RRE must provide a valid LOA to proceed with the formal appeal.
Modification: Recovery agents may now view the Open Debt Report on the MSPRP, if the agent has an active MSPRP account with a TIN matching one submitted on the RRE’s TIN Reference File (Section 6.3.1.2).
Impact: We applaud CMS and the BCRC for recognizing the increased need to provide transparency to the entities that are often in charge of addressing conditional payment risks. Allowing recovery agents to access Open Debt Reports will be a major improvement for claims payers, recovery agents, and ultimately CMS and its contractors. ECS was an early adopter of the Go Paperless process and we expect to seamlessly integrate regular use of the Open Debt Report into our conditional payment services.
Modification: ORM Termination Date field number 79 was corrected for the Event Table (Section 6.9.1).
Impact: This corrects a type where the Event Table incorrectly referenced ORM Termination Date as field number “99” in the prior version of the User Guide.
Modification: The expiration date for the OMB Control Number of the Paperwork Reduction Act (PRA) Disclosure Statement (before the Table of Contents) has been updated to 01/31/2025.
Impact: None
Modification: The CP13 soft edit for no fault policy limit amount has decreased from $1000 to $500 (Appendix F).
Impact: CMS reduced this soft-edit threshold, as the industry informed the agency and its contractors that there are some no fault policies with very low limits, for instance some motorcycle policies.
Modification: For the TIN Reference File, the Go Paperless Indicator is no longer required when submitting the Recovery Agent TIN (Field 25) (Appendix G).
Impact: None. This simply indicates that when a Third Party Recovery Agent (TPRA) is identified in the TIN Reference File, the population of the TPRA’s Tax ID Number is sufficient, and the TPRA Go Paperless indicator is not needed.
ECS will continue to monitor for additional updates. Over the next several weeks, we expect to introduce additional services to highlight the use of the Open Debt Report to augment conditional payment resolution. For any questions about this update, please contact Scott Huber at scott.huber@examworkscompliance.com or 678-256-5135.