Revised Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) Section 111 Non-Group Health Plan (NGHP) User Guide
This posting was first published on DRI Today's Blog (forthedefense.org) on April 17, 2015. It is reprinted here with permission.
The Centers for Medicare and Medicaid Services (CMS) released a revised version of the MMSEA Section 111 NGHP User Guide on April 6, 2015. The revised User Guide is version 4.6. The revisions are the results of an NGHP Section 111 Alert issued on November 25, 2014, regarding Section 111 querying with partial Social Security Numbers (SSNs). The revisions were made to Chapter IV: Technical Information (pp. 1-1 (summary of revisions), 8-6) and Chapter V: Appendices (p. 1-1 (summary of revisions) and Table F-1). The revisions inform Responsible Reporting Entities (RREs) of the steps they need to take to remain in compliance with the NGHP Section 111 reporting requirements when RREs or their agents query using partial SSNs and receive a response indicating the information they submitted identified multiple Medicare beneficiaries. When this occurs, RREs will receive the disposition code “DP” (for duplicate) or other messaging on the Beneficiary Not Found page indicating multiple Medicare beneficiaries were identified. When RREs receive a response indicating multiple beneficiaries have been identified based on the partial SSN and other required query information, RREs are instructed to:
1) verify that the SSN, name, gender, and date of birth were entered accurately and re-submit, and
2) resubmit the individuals information using the full 9-digit SSN (if available).
If a match is still not located after resubmission, RREs must call the Benefits Coordination & Recovery Center (BCRC) at 855.798.2627 and file a self-report with the BCRC customer service representative to remain in compliance.
NGHP Section 111 Alert:
CMS also issued an NGHP Alert on April 8, 2015. The Alert reminds RREs that beginning on October 1, 2015, RREs will be required to report ICD-10-CM diagnosis codes on claim reports with a CMS Date of Incident (DOI) on or after October 1, 2015. The Alert encourages RREs and their reporting agents to commence testing with ICD-10-CM codes if they have not already done so. While testing is not required, it is strongly encouraged. Testing is the only way for RREs to ensure they will be able to beginning reporting with ICD-10-CM diagnosis codes on October 1, 2015.
Additional information regarding NGHP Section 111 reporting is available at http://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Non-Group-Health-Plans/Overview.html, including links to the revised NGHP Section 111 User Guide and all NGHP Section 111 Alerts.
The material in this publication was created as of the date set forth above and is based on laws, court decisions, administrative rulings and congressional materials that existed at that time, and should not be construed as legal advice or legal opinions on specific facts. The information in this publication is not intended to create, and the transmission and receipt of it does not constitute, a lawyer-client relationship.
Content contributed by attorneys of Troutman Sanders LLP and Pepper Hamilton LLP prior to July 1, 2020, is included here, together with content contributed by attorneys of Troutman Pepper (the combined entity) after the merger date.