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CMS releases version 7.3 of the Non-Group Health User Guide

August 23, 2023 · Medicare Insights Team

The Center for Medicare and Medicaid Services (CMS) released an updated Non-Group Health Plan (NGHP) User Guide, Version 7.3, dated August 7, 2023, which includes some changes. A copy of the guide can be accessed at the CMS website.

Internet Explorer no longer supported

On June 14, 2022, Microsoft Internet Explorer browser reached end of life status. As a result, CMS removed all references to Internet Explorer being a supported browser.

Section 6.3 pertaining to Ongoing Responsibility for Medicals (ORM) Guidance (Updated)

The CMS NGHP Guide 7.2 published on June 5, 2023 sought to clarify the guidance on ORM. In the guide, CMS provided additional advice for actions by the RRE that would trigger an ORM claim. In addition, the physician statement was clarified. The following was added to Section 6.3 in Chapter III:

“The trigger for reporting ORM is the, 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.”

CMS NGHP Guide 7.3 seeks to further clarify ORM triggers and how ORM impacts payments for treatment. Section 6.3 in Chapter III now reads as follows:

“The trigger for reporting ORM is the determination to assume ORM by the RRE, which is when the RRE learns, through normal due diligence, that the beneficiary has received (or is receiving) medical treatment related to the injury or illness sustained. Required reporting of ORM by the RRE does not necessarily require the RRE to have made payment for Medicare-covered items or services when the RRE assumed ORM, nor does a provider or supplier necessarily have to have submitted a claim for such items or services to the RRE for the RRE to assume ORM. The effective date for ORM is the DOI, regardless of when the beneficiary receives the first medical treatment or when ORM is reported.”

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

A determination by the RRE to accept ORM.
The RRE learns, through normal due diligence, that the beneficiary received medical treatment related to the injury or illness sustained.

It is worth noting that the payment of medical benefits or submission of a claim does not determine whether or not ORM must be reported. On one hand, not removing payment of a claim from the equation might indicate that the insurer paid medical benefits but did not accept ORM. As an example, the jurisdiction in question has a pay-without-prejudice statute requiring the insurer to pay some medical benefits while investigating the claim or determining 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 is treated without the insurer being notified, the insurer may not be aware that it must report ORM. This could create a situation where the RRE may be out of compliance and not be aware that it should have reported ORM. The recent addition also notes that “through normal due diligence” language refers to the RRE’s knowledge of treatment. Unfortunately, this doesn’t clarify what is the required level of due diligence.

Unsolicited Response File Updates

CMS will provide a monthly file regardless of whether any claims have been updated. If there is nothing to report, the RRE will receive an empty file. CMS also clarified which folder the RRE should check to pick up the file. The files will be placed in the claim response file folder.

Optum can help with Your Section 111 reporting needs

As a longtime trusted Section 111 reporting agent for many companies, Optum stands ready to help you navigate CMS’ evolving Section 111 reporting requirements and meet your compliance needs. Contact us for more information on how we can help.

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