CMS Publishes NGHP User Guide Version 7.0
by F. Fairchok
CMS published an update to the NGHP User Guide on January 9, 2023. In addition to several minor updates, Version 7.0 announced a new Unsolicited Response File that will be introduced in July 2023 and added visibility for recovery agents to the Open Debt Report.
Unsolicited Response File
New functionality will be added to the reporting process when CMS introduces a new Unsolicited Response File in July 2023. This file will communicate to the Responsible Reporting Entity (RRE) any updates to Ongoing Responsibility for Medicals (ORM) records that have been submitted by the RRE in the previous 12 months. These changes may be made by entities outside of the Mandatory Insurer Reporting process and as a result the RRE may be unaware of all changes made to their reported record. The new Unsolicited Response File will provide visibility to the RRE when those records have been modified.
Once the RRE opts-in via the Section 111 Coordination of Benefits Secure Website (COBSW), the Unsolicited Response File will be provided monthly. A review of the structure shows that CMS will be providing the following information in the file:
- Beneficiary identifiers such as Medicare ID, first and last name, date of birth, and gender
- Insurer name and address
- Attorney name and address
- A Modifier Type Code and Modifier Name to identify the last entity that changed the . The User Guide provides the following list of three-character Modifier Type Codes along with the associated Modifier Name (if available):
- BCR – BCRC Contractor
- CBN – Beneficiary Name
- CEM – Employer / Other Plan Sponsor Name
- CIN – Insurer Name
- DSA – Name of Voluntary Data Sharing Agreement entity (VDSA)
- ECR – Contractor numbers 11139, 11141, 11142, 11143
This code indicates change was made due to information from another Medicare contractor
- PRV – Provider name
- RRE – Name of the RRE
- WCS – Workers’ Compensation Review Contractor
- A Change Reason Code that identifies the reason for the last change to the MSP occurrence. The User Guide presents the following list of Change Reason Codes and descriptions:
- CT – Change Termination Date
- DO – Mark occurrence for deletion
- II – Insurance information change
- UK – Unknown
- Blank value – System generated, reason unknown
Open Debt Report
Recovery Agents will now be able to view the Open Debt Report on the Medicare Secondary Payer Recovery Portal (MSPRP). To view the report, the Recovery Agent TIN must be submitted in the TIN Reference File and the Recovery Agent must have an active MSPRP account with a matching TIN.
Changes were made to the TIN Reference File in version 6.7 of the User Guide (released in January 2022) that support this functionality. With that update, the Recovery Agent TIN was added as field 25 of the TIN Reference File Detail Record (Table B-2 in Chapter V – Appendices).
Other updates in version 7.0 include the following, many of which have been previously announced:
- CP13 soft edit policy limit has decreased from $1000 to $500 (Appendix F).
- The Go Paperless Indicator is no longer required when submitting the Recovery Agent TIN (Appendix G).
- CMS will maintain the $750 recovery threshold for 2023. (See our blog on this topic)
- Information on Recovery Agents has been clarified to emphasize that such agents need written authorization to pursue any post-demand actions (Section 6.3.1 in Chapter IV – Technical Information).
- A correction has been made to the ORM Termination Date field number in the Event Table (Section 6.9.1 in Chapter IV – Technical Information).
The new functionality provided by the Unsolicited Response File introduced in this update may be optional for the reporting process, but will give RREs a way to monitor their recently reported claims for changes made by other entities who touch the process. As introduced, the ability to monitor changes made to ORM records is limited, considering that ORM may have been established with CMS as early as 2011 (initial reporting). CMS will begin providing this new file response in July 2023, so IMPAXX will monitor any new developments in this area as well as any changes made to the information delivered in version 7.0 of the User Guide.
If you have questions regarding this article and/or any changes made in version 7.0 of the User Guide, please don’t hesitate to email us at [email protected]. If you are looking for guidance on Section 111 reporting compliance, our experienced Medicare Secondary Payer Reporting services team collaborates with clients to customize their compliance experience and meet their unique needs and requirements. Contact us today to learn more.