CMS Issues NGHP User Guide 6.2

CMS released version 6.2 of the NGHP User Guide on January 21, 2021. The document is dated January 11, 2021 and contains some significant updates to Section 111 reporting processes.

Summary:

First, let us begin with a quick summary of the changes CMS has made within the text of User Guide 6.2:

  • Liability Threshold: The threshold for physical trauma-based liability insurance settlements will remain at $750. This is not a change but confirmation that the existing threshold limit will continue to be applied in these cases.
  • CP03 Hard Error Status: CMS is retracting a change made in the last update to the User Guide, version 6.1. The retraction is that error code CP03 will not be considered a soft error on April 5, 2021, as previous stated. CP03 will continue to be a hard error, as it had been previously, and will cause the rejection of a claim with an SP disposition code.
  • ORM Termination: CMS will now allow an ORM termination date to be up to 75 years from the current date. The previous limit for ORM termination dates was set to “6 months greater than the file submission date.”
  • Policy Number: The policy number is now a key field regarding identification of unique claims by CMS.
  • CMS is making changes to certain electronic file transfer processes. Of the four methods to transfer Section 111 data to CMS, three of those involve file exchanges and the remaining process is Direct Data Entry, or DDE. CMS is modifying one of the file transfer methods known as Connect:Direct, and any RRE or reporting vendor utilizing this method will need to adapt to those changes before CMS makes the final cutover in April 2021.

Deeper Dive:

The changes CMS presents in this User Guide update should not be taken lightly. For the sake of brevity in this article, we will not discuss the change to the file transfer process in depth as this very technical and likely out of scope for most readers. Suffice it to say that if an organization or vendor partner uses that methodology to send and receive files, there are programmatic changes that must be made, with haste, to ensure file naming conventions and connectivity are in place before CMS performs their final cutover in April 2021.

The clarification by CMS that the CP03 error code will remain a hard error is important to note, as CMS realized that without integrity to the Office Code/Site ID field there will be a potential breakdown in the delivery of mail to correct addresses. While smaller responsible reporting entities may not rely heavily on the Office Code/Site ID field, many larger ones do, and the field is used extensively at the TPA level to route information to the appropriate claim handling office. As such, CMS realized that not enforcing this error could create many issues in the recovery process which relies heavily on paper mail.

Next, the change made in this update to allow ORM termination dates that are 75 years in the future is a substantial change from the previous limit of six months that has been in effect since the start of production reporting in 2011. Often a pain point for the RRE or TPA, the six months put a burden on them to manage data when ORM could be terminated in the future by statute or other limitations. CMS effectively forced them to hold the ORM termination date back artificially until reaching the six-month window or face the rejection of the claim with an SP error code. The new limit will allow the data to flow to CMS so that a follow-up process does not need to monitor the claim to transmit the ORM termination date.

Lastly, but perhaps most significant of the changes noted in this User Guide update, is the change making Policy Number a key field. For those that are not involved deeply with the process, CMS uses “key fields” to identify unique claims and understand how to update them once received. Since the beginning of live reporting, CMS had identified the key fields as the CMS Date of Incident, the Plan Insurance Type, and the ORM Indicator. These three key fields were also aligned with the claimant SSN making it a fourth key field. CMS is now adding the Policy Number as an additional key field. Changes to the Policy Number field on a reported claim will now facilitate a delete transaction of the previously reported data and an add transaction of the modified claim.


In the last article published, we wrote a closing paragraph titled “The Elephant in the Room” and addressed the idea that the changes from that User Guide update were preparatory around rulemaking for Civil Money Penalties. It is our opinion that these new updates, specifically around Policy Number and ORM Termination Date, are a further progression for CMS to clean up the processes and data to move toward assessing fines.

It is important to note that these revisions come just two months after the last update issued, with three updates since October 5, 2020. CMS is moving with a swift pace and reporting platforms and processes must be quickly maintained to keep up. If you are concerned about the state of your reporting, or about the information presented here today, please let us know at [email protected].

 

Please visit our resource page here to link to the NGHP User Guide 6.2.