June Update to the NGHP User Guide – Version 7.2 Clarifies Ongoing Responsibility for Medical Medicare Reporting Requirements

Written by: Kathy Bell

Yesterday, on June 5, 2023, the Centers for Medicare & Medicaid Services (CMS) published an updated NGHP User Guide (Version 7.2) which provides additional guidance regarding Ongoing Responsibility for Medicals (ORM) reporting. If you work with workers’ compensation or no-fault/auto/MedPay/PIP claims, these updates are very important to note.

Chapter III, Section 6.3.2 (ORM Termination) now provides clarification on the date used to terminate ORM when relying upon a physician’s statement:

·       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.

Additionally, Chapter III, Section 6.3 (ORM Reporting) now expands the definition of when ORM is to be reported.:

“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”.

Section 1: Sanderson Firm's Analysis of Reporting Claims and CMS Requirements

The reporting of claims regardless of whether a claim has been submitted could significantly affect the reporting of workers’ compensation and no-fault claims. Additionally, it seems overreaching for CMS to require RREs to report ORM when no claim has been filed and the RRE may not be on notice. 

As CMS continues to provide clarification regarding the reporting of ORM, we continue to encourage RREs to look at their Section 111 data to ensure they are in compliance ahead of currently scheduled February 2024 Civil Monetary Penalty Rulemaking.

Chapter IV, Section 6.2.5.2 (Special Default Diagnosis Code for Liability – NOINJ Code) now states that ‘NOINJ’ claims are no longer required to be reported:

”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.”

Section 2: Sanderson Firm's Perspective on Changes to 'NOINJ' Diagnosis Code Reporting

CMS has pointed out in the User Guide that the ‘NOINJ” code may be used under extremely limited and specific circumstances.  This has not changed, and RREs should be cautious when making the decision to use the ‘NOINJ’ code and subsequently not report these claims.  Sanderson Firm is available to review the claim and provide guidance on whether the claim should be reported through Section 111.

Chapter IV, Section 7.5 (NGHP Unsolicited Response File) now confirms that RREs may receive a monthly unsolicited response file for NGHP ORM records. It further states:

“The only entity other than the RRE who can update these records is a BCRC CSR/Analyst on behalf of the (verified) beneficiary, for an access to care issue.   ORM is not terminated due to entitlement.  Updates made by a BCRC Call Center representative based on a call from the RRE will also be noted in this file.”

CMS has also updated the information that will be included in the response file:

·       Key matching fields, including the last DCN submitted by the RRE

·       Current values for identifying portions of the records in question

·       The most recent beneficiary entitlement information (though changes to this information will not trigger the NGHP Unsolicited Response file)

·       The source of the update

·       The reason for the update

·       The date the record was last changed

Section 3: Sanderson Firm's Commentary on NGHP Unsolicited Response File and Updates

This information is to be available starting in July.   New RREs may opt-in to the response file during the registration process for Section 111 COBSW application.  Existing RREs may opt in or out using the RRE Information option on the RRE Listing Page.  The Account Manager for the RRE will be able to assist in setting this up. 

At Sanderson Firm, we serve as a Medicare Section 111 Reporting Agent, ensuring our clients are following MSP and Section 111 Reporting regulations. If you have any questions regarding this NGHP User Guide update, our Section 111 Reporting Services, or any other Section 111 compliance matters, please do not hesitate to contact us.