On June 28th, Centers for Medicare & Medicaid Services (CMS) made two announcements. The first is notice of the updated MMSEA Section 111 Group Health Plan (GHP) User Guide, while the second concerns a new technical alert regarding the inclusion of Part D information in Section 111.

Updated MMSEA Section 111 Group Health Plan (GHP) User Guide and GHP 270/271 Health Care Eligibility Benefit Inquiry and Response Companion Guides

A summary of the updates that have been made in Version 6.2 of the MMSEA Section 111 GHP User Guide are listed here:

The CMS electronic file transfer (EFT) file-naming conventions for inbound and outbound files have been updated (Section 8.1.1).

To provide more accurate direction to submitters, instead of receiving the RX 07 error code (Beneficiary does not have Part D enrollment), Disposition Code 51 will be returned for those records where the submitted individual is not entitled to Medicare Part D (Appendix D).

A new Modifier Type Code (PVR) and Name (From a provider) have been added for unsolicited MSP response files, and the DTM code (Name of employer submitting the Data Match Questionnaire Response) has been removed (Section 7.2.10.6).

The following will become effective December 11, 2021:

Under the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT Act) for Patients and Communities, Section 111 Responsible Reporting Entities (RREs) who provide primary prescription drug coverage must submit this information through the Section 111 process. To support their efforts, the Query-Only Response File layout will be updated to provide the most recent Part D enrollment information for beneficiaries. Additionally, process steps for installing and configuring the HIPAA Eligibility Wrapper (HEW) software will also be provided (HEW Query-Only Response File Record – Version 4.0.0, Appendix I).

The full guide can be downloaded here at CMS.gov.

Medicare Secondary Payer (MSP) Mandatory Reporting Provisions Section 111 of the Medicare, Medicaid, and SCHIP Extension Act (MMSEA) of 2007

The purpose of the latest alert is to notify Group Health Plan (GHP) RREs of changes being made to the Query Only Response File. Effective December 13, 2021, RREs will need to provide current Part D enrollment information for a beneficiary if the profile indicates that it provides network primary prescription drug coverage via Section 111 reporting. Additionally, three new fields will be added to the Query Only Response File layout.

The full alert can be downloaded here at CMS.gov.

For questions regarding these updates and how they may affect you and/or your clients workers’ compensation or liability settlements, please contact Medivest here or call us at 877.725.2467.