CMS Releases NGHP User Guide Version 8.2
by F. Fairchok and B. Smith
The Centers for Medicare & Medicaid Services (CMS) released an update to the Non-Group Health Plan (NGHP) Section 111 Reporting User Guide on November 18, 2025. This update has a publication date of October 6, 2025, but was delayed due to the government shutdown. User Guide Version 8.2, contains changes related to the new requirements around reporting Workers’ Compensation Medicare Set-Aside (WCMSA) information and TPOCs associated with those claims, along with other minor updates.
Reporting Multiple Records for a Single Individual
CMS issued new guidance to clarify situations where it may be appropriate to submit records for a single individual in Chapter III, Section 6.5.1.3. These updates address the reporting of multiple TPOCs for different dates of incident and as well as reporting an MSA that settles multiple claims.
Single settlement resolving multiple incidents (different Dates of Incident) – Where there are multiple incidents (multiple dates of incident) being resolved with one TPOC, the RRE shall report the earliest date of incident and include all diagnosis codes being settled for all dates of incident. This applies regardless of the timing of the subsequent dates of incident, the nature of the injuries, or any allocation made to each date of incident in the settlement documents. This ensures that all medicals that were released by the settlement are accurately recovered while still affording the beneficiary a dispute and administrative appeal process if any claims are erroneously identified.
Medicare Set-Asides – As it relates to multiple dates of incident, an MSA, if applicable, shall be reported under the same guidance as above. That is, the earliest date of incident, if only one TPOC is made. If multiple TPOCs are submitted, but only one MSA is reported, the MSA shall be reported on the first TPOC only. Where there are multiple defendants (RREs) reporting in this scenario, the same guidance applies to MSAs as it does to TPOCs.
Length of Time to Generate Response Files
CMS also updated Chapter IV: Technical Information – reducing the number of days to return a response to the quarterly Claim Input File. The User Guide now states:
The response file will be returned to you within 33 days of receipt of your input file using the same method you used to send your input file (HTTPS, SFTP, or Connect:Direct).
Changes to Unsolicited Response File Reason Codes
Section 7.5, NGHP Unsolicited Response File, has also been updated. Responsible Reporting Entities (RREs) may opt in to receive a monthly Unsolicited Response File for NGHP ORM records. The file alerts RREs of records they submitted that were updated within the last month by the BCRC CSR/Analyst on behalf of the beneficiary to access care. Starting in April 2026, new reason codes will be available as part of the file to further improve the granularity and clarity of updates to Medicare Secondary Payer (MSP) and drug coverage records. The new codes have been added to Table 7-4 of the Guide as shown below:
Recovery Agent TIN
The TIN Reference file must contain the Recovery Agent’s Federal Tax Identification Number if the Recovery Agent’s Mailing Name is submitted. This requirement went live with CMS on October 6, 2025.
Commentary
CMS representatives previously provided various guidance options for claims being reported for the same claimant with multiple dates of injury but have now issued official directives which may be extremely difficult for some Responsible Reporting Entities (RREs) to implement. Some claim systems will not have the capacity to report in this manner, which may result in significant time and expense for RREs to reconfigure. Also, there is no clear indication of how reporting everything on the earliest claim, which may be the claim with the least exposure, will impact conditional payment recovery. The burden will be placed on the beneficiary and insurer to dispute any incorrect demands. The way settlements are structured may also be impacted resulting in separate settlements for each claim to avoid potential issues.
We are still hoping CMS will reschedule the webinar that was cancelled in last month to discuss these changes in further detail, and to gain a better understanding of the downstream impact these changes could have on beneficiaries and RREs.
Additional Alerts Issued Recently by CMS
In addition to the updated NGHP User Guide, CMS recently released updates for the 2026 recovery thresholds and ICD Diagnosis Codes. Read our blogs on these alerts to learn more:
If you have questions about the recent alerts, any changes made in version 8.2 of the user guide, or are looking for further guidance on MSP compliance, please don’t hesitate to email our experienced MSP Reporting services team at [email protected].