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CMS Updates NGHP User Guide to Version 8.4

April 22, 2026
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User Guide spelled out in wooden blocks

by F. Fairchok

The Centers for Medicare & Medicaid Services (CMS) released an update to the Non-Group Health Plan (NGHP) Section 111 Reporting User Guide on April 13, 2026. The refreshed User Guide, Version 8.4, contains changes related to Ongoing Responsibility for Medicals (ORM) Termination, Total Payment Obligation to Claimant (TPOC) reporting claims, and COBSW functionality along with other minor updates.

ORM Termination

CMS updated the guidance for ORM Termination in Policy Guidance, Chapter III, Section 6.3.2. The third bullet in this section has been modified with additional text as follows (new text in red):

Where the insurer’s responsibility for ORM has been terminated per the terms of the pertinent insurance contract, such as maximum coverage benefits, or any other reason that is not prohibited by the terms of the insurance contract or applicable state or federal law.

Note: An insurer’s refusal to accept ORM, or to continue to accept ORM, is a valid ORM termination reason, provided that the refusal is permitted by applicable state or federal law and the terms of the insurance contract.

TPOC Reporting

CMS added an example to TPOC Reporting in Policy Guidance, Chapter III, Section 6.4. The example clarifies the TPOC Date when a settlement needs to be approved by a state entity as follows:

Example: The parties to a workers’ compensation case execute an agreement regarding the claim on 01/20/2026. The state requires the workers’ compensation commission to approve the final settlement details and said approval occurs on 02/05/2026. The TPOC date in this situation would be 02/05/2026 because it is the later of the date the agreement was fully executed and the date the court or commission approved the agreement.

Also, in Section 6.5.1.4 the note pertaining to wrongful death has been revised to the following:

Note: In order for the wrongful death theory of liability to preclude Medicare from recovering from a settlement, judgment, award, or other payment, complete documentation must be provided that shows what was claimed and released or had the effect of being released. Additionally, a citation to the appropriate state statute or case law that precludes recovery from a wrongful death settlement should be included with any such dispute or appeal.

COBSW Now Supports Submission of EDI Requests

New functionality has been added to the Coordination of Benefits Secure Website (COBSW) to allow for the submission and viewing of EDI requests sent to the EDI Representative (Introduction and Overview, Chapter I, Chapter 7). Once an RRE is selected the “Action” menu users now have an option to “View/Submit EDI Requests” as shown below:

White box with the word Action in black text at the top and a bulleted list of 8 items below it in blue text. The top item in the list > View/Submit EDI Request has a red box with a slight shadow around the text.

Once that option is selected, a form appears with further options for requesting the release or deletion of a file or submitting a request for something else under “other.”

White box with the words View/Submit EDI Request at the top. A form for RREs to complete to submit a request to their EDI Representative is below the text.

Commentary

Thoroughly reviewing each NGHP User Guide update is essential to maintaining compliance with CMS requirements to properly reporting claims. The update to User Guide 8.4 has several small adjustments around ORM Termination and TPOC reporting and announces the convenience feature added to the COBSW to send requests to your EDI representative. But this update also came out just two days prior to the rescheduled webinar that was intended to address Workers’ Compensation Medicare Set-Asides (WCMSA).

That webinar was highly anticipated as there was hope that CMS would provide guidance to the industry related to how to report multiple claims tied together with a single WCMSA. The current guidance creates challenges due to the way claims systems operate without substantial circumvention of processes and controls. Some of the concerns we have heard from the industry include:

      • Complicating claim data where multiple injuries need to be represented on a single incident date
      • Unbalancing financial reserve amounts
      • Disrupting state reporting processes
      • Increasing adjuster work due to confusion from this guidance
      • Increasing Conditional Payment activity as multiple ICD Diagnosis Codes will be listed on the reported claim with the earliest Date of Incident instead of the claim that owns those codes

Unfortunately, CMS did not address concerns around the current guidance during their webinar on April 15. Hopefully we will receive further details from them soon on this specific topic. CMS may want to consider a pause to the current guidance before the data is tainted by entities trying to comply.

If you have questions about updates made in version 8.4 of the guide, or are looking for further guidance on Medicare Secondary Payer (MSP) compliance, please don’t hesitate to email our experienced MSP Reporting services team at [email protected].