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CMS releases version 7.2 of the Non-Group Health User Guide

June 13, 2023 · Medicare Insights Team

On June 6, the Center for Medicare & Medicaid Services (CMS) released an updated Non-Group Health Plan (NGHP) User Guide, Version 7.2, which includes important changes. A copy of the guide can be accessed at the CMS website.

Guidance on determining ORM Termination based on physician statement

In Chapter III, Section 6.3.2, of the guide, CMS added language to explain how an ORM (Ongoing Responsibility for Medicals) may be terminated when there is a physician statement:

Where an RRE* is relying upon a physician’s statement to terminate ORM, the ORM termination date to be submitted should be determined as follows:

Where the physician’s statement specifies a date as to when no further treatment was required, that date should be the reported ORM termination date.
Where the physician’s statement does not specify a date when no further treatment was required, the date of the statement should be the reported ORM termination date.
Where the physician’s statement does not specify a date when no further treatment was required, nor is the statement dated, the last date of the related treatment should be used as the ORM termination date.

* responsible reporting entity

Guidance on triggers to determine ORM clarification

In Section 6.3, CMS provides additional guidance for actions that would trigger an ORM claim:

The trigger for reporting ORM is the assumption of ORM by the RRE, which is when the RRE has made a determination to assume responsibility for ORM and when the beneficiary receives medical treatment related to the injury or illness. Medical payments do not actually have to be paid, nor does a claim need to be submitted, for ORM reporting to be required. The effective date for ORM is the DOI, regardless of when the beneficiary receives the first medical treatment or when ORM is reported.

This new language creates a two-part requirement for reporting ORM:

A determination by the RRE to assume ORM
The beneficiary receives medical treatment related to the injury or illness

It is worth noting that payment of medical benefits or the submission of a claim does not determine whether or not ORM must be reported. This can create ambiguity for RREs in making a determination of whether ORM must be reported. On one hand, not requiring payment of a claim to be a factor can imply that the insurer paid medical benefits but did not accept ORM. For example, ORM may not need to be reported in a jurisdiction that has a pay-without-prejudice statute where the insurer may be required to pay some medical benefits while investigating the claim and during the process of deciding whether to accept ORM. On the other hand, the insurer may have accepted ORM, but may not know if the claimant has received treatment. For instance, if the claimant receives treatment without notifying the insurer, the insurer may not be aware that it must report ORM, thus creating a situation where the RRE may be out of compliance. In a subsequent webinar on June 6, 2023, CMS acknowledged the ambiguity and stated that it may address this issue in a future update.

New NGHP Unsolicited File specs have been simplified

Beginning this July, RREs that opt in will start to receive new unsolicited NGHP files on the second Sunday of each month. The purpose of these files is to advise RREs of submitted claims that have been updated by another party. This enables RREs to review the claims and update the data in its claim system for resubmission to CMS.

The modifier type and name have been streamlined to only reference updates from either the beneficiary or the insured. Change reason code options have been reduced to indicate a change to the ORM Termination date or that a claim was marked for deletion.

In the June 6 webinar, CMS also specified that Medicare beneficiaries who update Section 111 reporting will only be allowed to update the ORM termination date. While this restriction should give RREs a narrow scope of what to monitor in the Unsolicited File, RREs must make sure any other changes to Section 111 reporting are correct and accurate.

Reporting NOINJ for Liability claims is now optional

Until now, CMS has provided the special default diagnosis code “NOINJ” for non-medical liability claims in limited situations such as loss of consortium or a wrongful action. CMS is now making the reporting of NOINJ claims optional:

Note: In cases where the reporting of a liability record only meets the criteria for reporting a ‘NOINJ’ diagnosis code in Field 18, the reporting of the record is no longer required. However, it is optional for the RRE to report the record with the ‘NOINJ’ diagnosis code following the previously existing rules in the User Guide as follows:

When submitting the ‘NOINJ’ value in Field 18, all of the rest of the diagnosis fields must be left blank and Field 15 (Alleged Cause of Injury, Incident, or Illness) must be submitted with the value “NOINJ” or all spaces. All other required fields must be submitted on the claim report.

Optum can help with your Section 111 reporting needs

As a long-time, trusted Section 111 reporting agent, Optum is eager to help with Section 111 reporting and in navigating CMS’ evolving requirements. Our experts in Section 111 reporting will ensure that your compliance needs are met. Contact us for more information on how we can help you meet your Section 111 reporting or other Medicare Secondary Payer compliance needs.

For additional information, please contact Optum MSP Compliance Counsel, Michael Flower at michael.flower@optum.com (p) 813-627-2406.