CMS releases Section 111 NGHP User Guide (Version 6.9)

The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 NGHP User Guide (Version 6.9, October 3, 2022) regarding Section 111 reporting related to non-group health plans (liability, no-fault and workers’ compensation).1

As usual, CMS lists updates made in the beginning of each User Guide chapter in a “Summary” page. Reviewing these pages indicates that updates were made to Chapter IV (Technical Guidance) and Chapter V (Appendices). As outlined below, the summary pages list updates regarding Section 111 excluded and valid diagnosis codes for 2023 (including that this list is now being published solely in Excel format and contained on a dedicated page as part of CMS.gov) and the SP31 Error. In addition, other changes were also made which are not specifically outlined by CMS in the summary change page updates.

A general overview of the NGHP User Guide (Version 6.9) updates is as follows:

Section 111 excluded/valid diagnosis codes for 2023

CMS describes the changes made regarding Section 111 excluded and valid diagnosis codes as follows:

The Section 111 excluded ICD-10 diagnosis codes for All Types (E, L, D) and for No-Fault Plan Insurance Type D have been removed from this guide (previously Appendices I and J). Excel spreadsheets of the ICD-9/ICD-10 excluded and valid codes for FY 2023 are now available for download on CMS.gov at https://www.cms.gov/medicare/coordination-benefits-recovery-overview/icd-code-lists2

As per their usual schedule, CMS has published their annual October updates to their Section 111 specific excluded and valid diagnosis code listings which will take effect in January 2023. 

Regarding this update, there are two important changes to note:

First, CMS has published the newly updated excluded and valid code listings for 2023 solely via an Excel spreadsheet.  In prior years the excluded code listing was published both as part of the User Guide appendix and Excel spreadsheets posted to CMS’s Section 111 COB Website.  With this update, the excluded code listing has been removed from the User Guide appendices.

Second, as noted in the quoted excerpt above, CMS has created a new dedicated page at CMS.gov where both the current excluded and valid code listings now reside.  Previously these listings were available directly via a link within the Reference Materials file menu on the Section 111 COB Secure Website.  There is still an option available via the Reference Materials file menu, but that option will now redirect the user to the noted dedicated page at CMS.gov. 

SP31 Error

The Chapter V summary change page indicates that “the SP31 Error has been restored.  RREs will receive this error code when submitting records with effective dates greater than 90 days prior to Medicare entitlement (Appendix F).”3 

By way of background, in late 2020, CMS as part of NGHP User Guide (Version 6.1, November 10, 2020) had updated their process to begin returning an ‘03’ disposition code, instead of an SP31 error, in scenarios involving submissions of coverage records prior to a Medicare beneficiary’s entitlement date, as of April 5th, 2021.  Subsequent to this change, CMS as part of NGHP User Guide (Version 6.5, October 4, 2021) then began accepting records with MSP effective dates up to 3 months into the future rather than returning those coverage records with an ‘03’ disposition which eliminated the need for resubmission by the RRE.  However, notwithstanding these referenced updates, from our experience RREs would occasionally encounter scenarios in which CMS would still return an SP31 error indicating that the coverage record was not accepted due to a future entitlement/MSP effective date.  It appears that these scenarios may have occurred when entitlement/MSP effective dates happened to be more than 90 days into the future at the time of submission. 

Against this backdrop, CMS has now re-added the SP31 error code back into the NGHP User Guide as part of the Version 6.9 updates stating, as noted above, that “the SP31 Error has been restored. RREs will receive this error code when submitting records with effective dates greater than 90 days prior to Medicare entitlement (Appendix F).”4 On a servicing note, for those RREs who utilize one of Verisk’s Section 111 reporting platforms (MSP Navigator, ClaimSearch CMS or iComply), Verisk’s processes will continue to automatically resubmit any records returned with an SP31 error, as always, and therefore this should not require any technical changes.

Other Changes

From the authors’ review of NGHP User Guide (Version 6.9), it is noted that CMS has made other updates in the new User Guide in addition to those noted by the agency in the summary update pages.  These changes are outlined by CMS in Chapter V, Appendix M (Previous Version Changes) which, by way of note, includes reference to these changes updating items as contained in NGHP User Guide (Version 6.8).  However, based on the authors’ continual monitoring of CMS’s Section 111 releases and related research, it does not appear that the agency ever actually released a Version 6.8. Notwithstanding, these updates are important to note and are outlined as follows:

• Field 79 (ORM Termination Date)

A note was added to the Description field within the Claim Input File Layout (Appendix A) which reads: “If no ORM Termination Date is provided but an Exhaust Date for Dollar Limit for No-Fault Insurance (Field 62) is provided, then this date will be used to auto populate the ORM Termination Date.”  Technically, this is not a new change.  CMS’s process has automatically applied a termination date to their ORM coverage records in this fashion for quite some time although it appears this logic is being documented here for the for the first time.  Please note, in scenarios involving the exhaustion of no-fault benefits, it is still important to submit both the Exhaust Date for Dollar Limit for No-Fault Insurance and the ORM Termination Date in order to avoid any potential negative impact to downstream conditional payment recovery processes. 

• CJ02 and CJ06 error code updates (Appendix F)

The possible cause language for the CJ02 error was updated to remove a former bullet point which read, “has a date that is more than 75 years from the current date”, while wording of two additional bullet points was altered, although without any changes to technical implications.  The Possible Cause language for the CJ06 error remained the same and still reads, “Submitted ORM Termination Date (Field 79) is more than 75 years from the current date.”  However, the update to the CJ02 Possible Cause language removed the prior overlap in the description between these two error codes.  This would appear to clarify which error should actually be returned in the event that an ORM Termination Date greater than 75 years into the future is submitted.  The only change to the CJ06 error was within the Required Field column where the value provided was updated from “N/A” to “No”.

• Possible Cause description for the TN40 error (Appendix F)

This was updated to correct a reference to a previously incorrect field number.  The old Possible Cause description had referred to a “Y” value being populated within Field 25 (Recovery Agent TIN) and has now been corrected to reference a “Y” value populated in Field 24 (Recovery Agent Paperless Indicator) within the TIN Reference File. 

Questions?

Please contact the authors if you have any questions regarding CMS’s updates as discussed above or other issues related to Section 111 reporting.

1. As noted, CMS’s new NGHP User Guide is referenced as “Version 6.9.” In this regard, as noted in this article, CMS in Chapter V, Appendix M (Previous Version Changes) references certain updates being made in reference to a “NGHP User Guide (Version 6.8).”  However, from the authors’ continual monitoring of CMS’ Section 111 releases and related research, it does not appear that the agency ever actually released a Version 6.8 to the User Guide.
2. CMS’s NGHP Section 111 NGHP User Guide (Version 6.9, October 3, 2022), Chapter IV (Technical Information), Chapter 1, p. 1-1 and CMS’s NGHP Section 111 NGHP User Guide (Version 6.9, October 3, 2022), Chapter V (Appendices), Chapter 1, p. 1-1.
3. CMS’s NGHP Section 111 NGHP User Guide (Version 6.9, October 3, 2022), Chapter V (Appendices), Chapter 1, p. 1-1.
4. CMS’s NGHP Section 111 NGHP User Guide (Version 6.9, October 3, 2022), Chapter V (Appendices), Chapter 1, p. 1-1.

By Jeremy Farquhar and Mark Popolizio

Courtesy of Verisk

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