A Busy Week for MSP Updates: CMS Updates NGHP User Guide, Allows New Standard for ORM Termination

In addition to the PAID Act technical alert being released yesterday, CMS has issued an updated Section 111 NGHP User Guide version 6.4. Updates were provided to Chapter II: Registration Procedures, Chapter III: Policy Guidance, and Chapter IV: Technical Information.

This blog will list each chapter update by Chapter, although the update to the Policy Guidance chapter with a new Ongoing Responsibility for Medical (ORM) termination standard is arguably the most compelling update/change to the Guide.

Chapter II: Registration Procedures Updates

CMS added the following in conjunction with the release of the PAID Act technical alert yesterday. Please see our blog from yesterday for more information on this update:

The following will become effective as of December 11, 2020: In 2020, the Provide Accurate Information Directly Act (PAID Act) was passed to help NonGroup Health Plan (NGHP) Responsible Reporting Entities (RREs) better coordinate benefits by providing additional beneficiary enrollment information. With this Act, RREs will receive Part C (Medicare Advantage Plan) and Part D (Medicare prescription drug coverage) enrollment information for the past 3 years, as well as the most recent Part A and Part B entitlement dates, on the Query Response File (Chapter 3).

Chapter III: Policy Guidance Updates

CMS updated Section 6.3.2 of this chapter to allow a new standard/criterion for terminating ORM (this new standard is in addition to previously existing criteria for terminating ORM such as policy exhaustion, termination of responsibility under state law, and completed treatment as evidenced by a treating physician statement):

Where there is no practical likelihood of associated future medical treatment, which is reflected by meeting ALL of the following:

• No claims were paid with any diagnoses codes related to alleged ingestion, implantation, or exposure; and

• No claims were paid, for any medical item or service related to the case, within five (5) years of the date of service of any such claim; and

• Treatment did not include, nor were any claims paid related to, a medical implantation or prosthetic device; and

• The total amount paid by the insurer, for all medical claims related to the case, did not exceed $25,000.

Chapter IV: Technical Information Updates

CMS added the following update to this Chapter:

The Event Table, which helps RREs and their agents determine when, and how, to send records on the Claim Input File, has been updated to cover situations where ongoing responsibility for medicals (ORM) ends for one injury due to Total Payment Obligation to Claimant (TPOC), but then continues for another injury (Section 6.6.4). The CMS electronic file transfer (EFT) file-naming conventions for inbound and outbound files have been updated (Section 10.2). The following updates will become effective December 11, 2021: In 2020, the Provide Accurate Information Directly Act (PAID Act) was passed to help NonGroup Health Plan (NGHP) Responsible Reporting Entities (RREs) better coordinate benefits by providing additional beneficiary enrollment information. With this Act, RREs will receive Part C (Medicare Advantage Plan) and Part D (Medicare prescription drug coverage) enrollment information for the past 3 years. To support this Act, the Query Response File will be updated to include: Contract Number, Contract Name, Plan Number, Coordination of Benefits (COB) Address, and Entitlement Dates for the last three years (up to 12 instances) of Part C and Part D coverage. The updates will also include the most recent Part A and Part B entitlement dates. The HIPAA Eligibility Wrapper Software (HEW) software will also be modified to extract the additional fields from the response file. Finally, process steps for installing and configuring the HEW software will be provided (see Chapter V, HEW Query Response File Record – Version 4.0.0, Appendix K).

Commentary:

This new ORM termination standard which allows Responsible Reporting Entities (RREs) to terminate ORM in non-ingestion/exposure cases where no claims have been paid within the last 5 years and the total medical paid is $25,000 or less is certainly helpful for older claims where RREs could not previously terminate ORM.

We appreciate CMS broadening its standards but remain hopeful that CMS will continue to work toward additional broader standards to assist RREs in termination of ORM, particularly in lifetime medical states. Unfortunately, in lifetime workers’ compensation medical states (such as Texas), WC payers have lifetime responsibility for injury-related care and as such it is difficult for RREs to terminate ORM (unless the claimant passes away and the RRE is aware of such or if they now meet the new 5-year no medical paid/$25k or less paid in medical standard).

Inability to terminate ORM for lifetime results in not only coordination of benefits issues where the Medicare beneficiary may not be able to receive medical treatment, injury related or not, due to their old WC claim having ORM flagged in Medicare’s system. Some RREs in lifetime medical states have claimed to receive hundreds of calls a year from Medicare beneficiaries claiming that they are having their Medicare benefits denied due to the WC insurer’s inability to terminate ORM in their system!

This is a major problem as the WC insurer is simply complying with CMS standards for ORM termination, but it is interrupting Medicare beneficiary’s care and causing a burden on the carriers for fielding these Medicare beneficiary calls. Further, the RRE likely will continue to receive conditional payment demands/notices due to ORM remaining “Y,” but such charges are typically unrelated as the injured worker may not have treated for several years.

Just like CMS eventually expanded their Amended Review process for WCMSA determinations from 4 years to 6, we are hopeful that CMS will consider more aggressive ORM termination standards over time, such as no treatment rendered in the last 2 years (rather than 5) and a higher dollar threshold for total medical paid, such as $100,000.

Contact us with questions on the new NGHP User Guide.