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08/Jul/2024

On July 2, 2024, the Centers for Medicare & Medicaid Services (CMS) created the Non-Group Health Plan (NGHP) Applicable Plan Appeals Reference Guide version 1.1.

To download the NGHP Applicable Plan Appeals Reference Guide Version 1.1 by clicking here.

Summary of NGHP Applicable Plan Appeals Reference Guide Version 1.1 and the Updates

Much like how the Workers’ Compensation Medicare Set-Aside Arrangement Reference Guide focuses on the submission process for Workers’ Compensation MSA’s, this appeals reference guide seems more focused on appeals by employers’ WC plans as opposed to liability matters which would be handled by the beneficiary directly or their representatives, as it only references the Commercial Repayment Center (the “CRC”) as the entity to which to submit a first level Redetermination request.  Because many of our readers inquire about Medicare lien appeals in the liability space, for liability cases, first level Redetermination requests may also be submitted via the Medicare Secondary Payer Recovery Portal (MSPRP) or the Benefits Coordination Recovery Center (“BCRC”) at P.O. Box 138832, P.O. Box 138832, Oklahoma City, OK 73113.  The four step administrative appeals process prior to being able to appeal in federal District Court is similar for WC, No Fault, and liability cases but sometimes, the contractors hired by CMS to review the various stages may sometimes be different (and often are different in different parts of the country as well).

To clarify the process necessary to appeal based on the exhaustion of benefits, the list of required documentation has been updated (Section 4.1.1).

For Additional Information

Medivest will continue to monitor changes occurring at CMS and will keep its readers up to date when such changes are announced. For questions, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.

 


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08/Jul/2024

On July 2, 2024, the Centers for Medicare & Medicaid Services (CMS) updated the MMSEA Section 111 NGHP User Guide version 7.6. It has been posted to the NGHP User Guide page on CMS.gov.  The NGHP User Guide version 7.6 replaces Version 7.5 which was released on April 1, 2024.  The updated MMSEA Section 111 NGHP User Guide version 7.6 has been posted to the NGHP User Guide page on CMS.gov.

MMSEA III – July 1, 2024 – NGHP User Guide Downloads 7.6

Updates:  An expanded and specific definition has been to clarify the qualification of a cumulative injury for Section 111 NGHP reporting. (Chapter 2).

Updates:  There are no changes for this version.

Updates:   The submission of information related to Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) will be required for all records submitted with a TPOC date after April 4, 2025 (Section 6.5.1.1). As of January 1, 2024, the threshold for physical trauma-based liability insurance settlements will remain at $750. CMS will maintain the $750 threshold for no-fault insurance and workers’ compensation settlements, where the no-fault insurer or workers’ compensation entity does not otherwise have ongoing responsibility for medicals (Section 6.4).

Updates:  Information on how to resolve TIN address errors was added (Sections 6.3.3 and 6.6.5).

Updates:  An expanded and specific definition has been to clarify the qualification of a cumulative injury for Section 111 NGHP reporting (Section 3.2).

The language used to describe the date of incident and how a cumulative injury fits within that definition from CMS’ perspective with a caution note that CMS’ definition of cumulative injury is different from the insurance industry’s definition:

From Chapter 2, page 2-2, “CMS defines the Date of Incident (DOI) as follows:

  • The date of the accident (for an automobile or other accident);
  • The date of first exposure (for claims involving exposure, including; occupational disease, or any associated cumulative injury);
  • The date of first ingestion (for claims involving ingestion);
  • The date of the implant or date of first implant, if there are multiple implants (for claims involving implant(s); or
  • The earlier of the date that treatment for any manifestation of the cumulative injury began, when such treatment preceded formal diagnosis, or the first date that formal diagnosis was made by a medical practitioner (for claims involving cumulative injury).

Note: Cumulative injury refers to those categories of injuries that may persist or grow in severity, intensity, or pain but for which a formal diagnosis may not occur until a later date. Examples of cumulative injuries include, but are not limited to, carpal tunnel syndrome, or back pain that is not the result of an acute trauma. Exposure, ingestion, and inhalation injuries are not considered cumulative injuries for purposes of calculating DOI or any other reporting requirements. This CMS definition differs from the definition of that generally used by the insurance industry under specific circumstances. For the DOI used by the insurance and workers’ compensation industry, see Field 13 of the Claim Input File Detail Record in the NGHP User Guide Appendices, Chapter V.”

Updates:  The end-of-line character has been clarified for files using HEW software (270/271 File Translation).

 

For Additional Information

Medivest will continue to monitor changes occurring at CMS and will keep its readers up to date when such changes are announced. For questions, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.

 


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09/Apr/2024

On April 1, 2024, Centers for Medicare & Medicaid Services (CMS) updated the MMSEA Section 111 Non-Group Health Plan (NGHP) User Guide version 7.5. It has been posted to the NGHP User Guide page on CMS.gov.  The NGHP User Guide version 7.5 replaces Version 7.4 which was released on January, 30, 2024.

To download the updated MMSEA Section 111 NGHP User Guide 7.5 click here.

MMSEA III- April 1, 2024 – NGHP User Guide Downloads 7.5

Updates:  There are no changes for this version

Updates:  There are no changes for this version.

Updates:   The submission of information related to Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) will be required for all records submitted with a TPOC date after April 4, 2025 (Section 6.5.1.1). As of January 1, 2024, the threshold for physical trauma-based liability insurance settlements will remain at $750. CMS will maintain the $750 threshold for no-fault insurance and workers’ compensation settlements, where the no-fault insurer or workers’ compensation entity does not otherwise have ongoing responsibility for medicals (Section 6.4).

Updates:  The submission of information related to Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) will be required for all records submitted with a TPOC date after April 4, 2025 (Sections 6.1, 6.4.4, and 6.5). As of January 1, 2024, the threshold for physical trauma-based liability insurance settlements will remain at $750. CMS will maintain the $750 threshold for no-fault insurance and workers’ compensation settlements, where the no-fault insurer or workers’ compensation entity does not otherwise have ongoing responsibility for medicals (Section 6.4).

Updates:  Beginning April 4, 2025, CMS will collect information about WCMSAs through Section 111 reporting. To support this effort, related fields have been added to the Claim Input File Detail Record; note that as the current file layout is unchanged, all the not-yet-implemented codes are marked with an asterisk (*) in the field number to distinguish them from the those in the current file layout. Once they are in effect, all the asterisks will be removed and the fields that follow them will be renumbered. Error codes related to these fields have also been added to the Claim Response File Error Code Resolution Table (Appendix A and Appendix G).

Updates:  The end-of-line character has been clarified for files using HEW software (270/271 File Translation).

For Additional Information

Medivest will continue to monitor changes occurring at CMS and will keep its readers up to date when such changes are announced. For questions, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.

 


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25/Mar/2024

On Tuesday April 16, 2024, Centers for Medicare & Medicaid Services (CMS) will be hosting a second webinar regarding the expansion of Section 111 Non-Group Health Plan (NGHP) Total Payment Obligation to Claimant (TPOC) reporting to include Workers’ Compensation Medicare Set-Aside (WCMSA) information. After the first webinar in November, CMS received additional questions and feedback from the industry. The intent of this webinar is to ensure that RREs will be prepared for the change once implemented.

With that in mind, this webinar will include a background recap, summary of technical details, updated timelines and CMP impacts. The presentation will be followed by a question and answer session. Because this expansion impacts reporting of WCMSAs, it is strongly recommended that Responsible Reporting Entities (RREs) that report Workers’ Compensation settlements attend.


 

Date:  April 16, 2024
Time:  2:00 PM EST

Webinar Link: https://cms.zoomgov.com/s/1610015349?pwd=NHcza3NhcDlCdjM0cVhENWlNcFBjZz09
Passcode:  750766

Or to connect via phone:

Conference Dial In:  1-833-568-8864
Conference Passcode:  161 001 5349


 

Additional information about the most recent updates from CMS can be found here. If you have questions on how topics discussed in this webinar may affect your clients or your company, please contact Medivest or call us at 877.725.2467.

 


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26/Feb/2024

On Friday, February 23, 2024, Centers for Medicare & Medicaid Services (CMS) published an alert regarding the upcoming change to Section 111 reporting to include Workers’ Compensation Medicare Set-Aside (WCMSA) amounts for Workers’ Compensation settlements meeting the $750 threshold regardless of whether the WCMSA was submitted to CMS for approval or not.

“All MSA funding for WC settlements shall be reported regardless of whether or not an approval was previously sought from the CMS. This change will be prospective for the Total Payment Obligation to Claimant (TPOC)s on or after the implementation date. For example, records submitted on a production file with a TPOC date on or after April 4, 2025, will be subject to the new edits.”

Please note that testing of the new fields will be available as early as October 7, 2024. The full alert is available at in the Download section of the NGHP Alerts page here.

For Additional Information

Count on Medivest to help keep you up to date with the constant updates, guidance, and rule changes related to CMS’s enforcement of the MSP on a regular basis. For questions, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.

 


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31/Jan/2024

The January 18th, 2024 webinar hosted by Centers for Medicare & Medicaid Services (CMS) entitled Medicare Secondary Payer and Certain Civil Money Penalties (Non-Group Health Plan) is now available in the Download section of the What’s New page on CMS.gov. The webinar can be viewed in its entirety, or you may download the materials covered in PDF format by clicking here.   

Medivest will continue to monitor news and updates from CMS and will keep its readers up to date when important announcements are made. For questions regarding the information presented in this webinar or any other recent CMS updates, please reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467. 

 


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23/Jan/2024

On January 22, 2024 the Centers for Medicare & Medicaid Services (CMS) released their data for the Top 10 Section 111 Non-Group Health Plan Reporting Errors July – December 2023. The chart with the list of errors and their rank can be viewed below. A downloadable PDF of this chart along with an explanation of the error codes can be viewed here at the CMS website.

Medivest will continue to monitor news and updates from CMS, and will keep its readers up to date when important announcements are made. For questions about this chart or any other recent updates, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.


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04/Jan/2024

CMS will be hosting a webinar regarding Certain Civil Money Penalties Final Rule for NGHP Responsible Reporting Entities (RREs). The format will be opening remarks and a presentation by CMS that will include discussion of the Final Rule, the auditing process and important dates, followed by a question and answer session. RREs who would like to submit questions in advance of the webinar are encouraged to do so using the dedicated resource mailbox at Sec111CMP@cms.hhs.gov.


 

Date:    January 18, 2024
Time:    1:00 PM ET

Webinar Link:  https://cms.zoomgov.com/s/1614664558?pwd=enlySUNSSjF1UnMzUy9vRWJodWl1dz09
Passcode:        513018

Or to connect via phone:

Conference Dial In: (833) 568-8864
Conference Passcode: 161 466 4558

Important Note: This is a public webinar and there is no pre-registration needed. The webinar link should only be utilized the day of the webinar. Due to the number of expected participants, please log in at least 10 minutes prior to the start of the presentation.


 

CMS has also announced it will be hosting a webinar regarding Certain Civil Money Penalties Final Rule for GHP Responsible Reporting Entities (RREs). Information on that webinar can be found on CMS’s website.

Additional information about recent updates from CMS can be found here. If you have questions on how topics discussed in this webinar may affect your clients, please contact Medivest here or call us at 877.725.2467.


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19/Oct/2023

CMS will be hosting a Section 111 Workers’ Compensation Reporting Webinar on Monday November 13, 2023 applicable to all primary plans considered Non-Group Health Plans (NGHP) including Liability Insurance (including Self-Insurance), No-Fault Insurance and Workers’ Compensation. Section 111 is also known as Mandatory Insurance Reporting and CMS will be focus its webinar on the expansion of Section 111 Non-Group Health Plan (NGHP) Total Payment Obligation to Claimant (TPOC) reporting to include Workers’ Compensation Medicare Set-Aside (WCMSA) information.

As usual, the format will include opening remarks and then a presentation by CMS that will include background and timelines, followed by a question-and-answer session. CMS has indicated that “because this expansion impacts reporting of WCMSAs, it is strongly recommended that Responsible Reporting Entities (RREs) who report Workers’ Compensation settlements attend.”


 

Date:  November 13, 2023
Time:  1:00 PM ET

Webinar Link: htps://cms.zoomgov.com/j/1606789743?pwd=VzZ0Uk96ZWs1NUUvbm5xUnpJU2l4Zz09

Passcode: 100553

Or to connect via phone:

Conference Dial In: 1-833-568-8864
Conference Passcode: 160 678 9743

Due to the number of expected participants, please log in at least 10 minutes prior to the start of the presentation.


 

Additional information about recent updates from CMS can be found here. If you have questions on how topics discussed in this webinar may affect your clients, please contact Medivest here or call us at 877.725.2467.


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25/Jul/2023

On July 19, 2023, the Centers for Medicare & Medicaid Services (CMS) released their list of the Top 10 Section 111 Non-Group Health Plan Reporting Errors between January 1 – June 30, 2023. The chart with the list of errors and their rank can be viewed below. A downloadable PDF of this chart cane be found at the CMS website here.

Medivest will continue to monitor news and updates from CMS, and will keep its readers up to date when important announcements are made. For questions about this chart or any other recent updates, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.


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