CMS Releases NGHP User Guide Version 6.5

User Guide spelled out in wooden blocks

by Frank Fairchok, Vice President of Medicare Reporting Services

In what continues to be an exciting time of change in the Medicare Secondary Payer space, CMS released version 6.5 of the NGHP User Guide last week (dated 10/4/21). This new version provides additional updates around the evolving query processes in relation to the implementation of the PAID Act. While this article will cover those changes in-depth, we start with a summary of other changes highlighted, some of which are substantial.

Direct Data Entry (DDE)
Responsible Reporting Entities (RREs) that utilize the Direct Data Entry (DDE) method of reporting claims will now have access to the Beneficiary Lookup function on the Coordination of Benefits Secure Website (COBSW). The DDE method of reporting is for RREs that have a small number of claims to report – typically under 500 per year. Previously, RREs using this process would usually find out if the claimant was a Medicare beneficiary as they reported the claim. Now, an RRE using this reporting method will be able to query the claim using the Beneficiary Lookup function, which will also provide the RRE with visibility into the Part C and Part D plan information in addition to Part A and Part B entitlement start and end dates.

Acceptance of Records with Future Entitlement Dates
CMS will begin accepting claim reports where the entitlement start date is within three months of the claim submission date. This change was communicated by CMS on September 27, 2021 (as noted in our blog) and the User Guide has been updated to include this language.

Ongoing Responsibility for Medicals (ORM) Termination
CMS added a clarification around the reporting requirements when the CMS date of incident (DOI) is prior to December 5, 1980 as follows:

“In cases where exposure has ended prior to December 5, 1980, and there is not yet a settlement, judgment, award, or other payment, it would be inappropriate, and counter to the MMSEA Section 111 reporting obligations, to report such a claim.”

ICD Code Update for 2022
The ICD 10 codes located in Appendices I and J of Chapter V have been updated for 2022. Appendix I contains codes excluded for all Section 111 reporting and Appendix J contains codes excluded for reporting claims that are plan insurance type D, no-fault insurance.

PAID Act Changes to the Beneficiary Lookup Tool
On October 4, 2021 all RREs, regardless of reporting method, will have access to the Medicare Part A and Part B entitlement start and end dates, as well the last three years of Part C and Part D plan information, if the beneficiary has been enrolled in such plans. Access is provided through the Beneficiary Lookup tool available on the COBSW.

For further information about using the Beneficiary Lookup tool, please see our recent article here.

In our last update on the PAID Act, we discussed how CMS has been clear that an RRE is not required to use the plan data returned in the query process due to the PAID Act. While it is true that the act does not stipulate the use of such data, an RRE should closely evaluate how this data will likely enhance their overall MSP compliance and provide an opportunity to reduce future litigation risk.

MEDVAL understands that each additional step of MSP compliance adds to our clients’ concerns around cost and complexity. So, we work with our clients to achieve the highest level of compliance while controlling costs, whether those costs are settlement specific or stem from related services.

Now is the time to explore how PAID Act data can be used to reduce your future exposure and risk, and MEDVAL is ready to assist. An experienced Medicare Secondary Payer services partner, we also collaborate with clients to customize their compliance experience and focus on meeting their unique needs and requirements throughout the process. Contact us today to build a process that helps protect your organization’s interests while keeping your costs contained.