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  • Matthew T. Dorius, Esq.

CMS Issues Updated Section 111 User Guide


CMS recently released a new version of the User Guide (Version 5.9) including the updates below.


• The User Guide now states that “while the threshold for physical trauma-based liability insurance settlements remains at $750, this threshold does not apply to non-trauma liability reporting for alleged ingestion, implantation, or exposure cases. Any settlement, regardless of amount, should be reported for these types of cases.” CMS noted in the User Guide that this was added as a reminder. The last version of the User Guide (Version 5.8) indicated that the $750.00 threshold applies to physical trauma-based liability claims. However, prior versions of the User Guide did not specify that the $750.00 threshold does not apply to liability claims involving ingestion, implantation, or exposure.


• When reporting ORM for no-fault claims, the No-Fault Insurance Limit field must include the combined total amount of Med Pay and Personal Injury Protection (PIP) benefits. CMS issued this guidance in a recent alert discussed in our post at https://www.carrallisonmsa.com/post/cms-alert-regarding-reporting-of-no-fault-insurance-limits.


• The User Guide now reflects that a threshold error will be triggered if the dollar amount of the No-Fault Insurance Limit and/or the cumulative value of all reported TPOC amounts (detailed and auxiliary records) exceeds $99,999,999.99. Previously, the User Guide indicated that the maximum amount was $99,999,999.


• The description of the claim response error code CR02 (for the Claimant 1 representative last name) has been updated to reflect the correct field number for the Claimant 1 representative last name (Field 65 instead of Field 85).


• The list of excluded ICD-9 and ICD-10 codes has been updated to remove the diagnosis codes below. However, please note that these codes are still on the list of excluded codes for no-fault claims.


ICD-9 codes

427.31 Atrial fibrillation

427.32 Atrial flutter


ICD-10 codes

I48.0 Paroxysmal atrial fibrillation

I48.1 Persistent atrial fibrillation

I48.11 Longstanding persistent atrial fibrillation

I48.19 Other persistent atrial fibrillation

I48.2 Chronic atrial fibrillation

I48.20 Chronic atrial fibrillation, unspecified

I48.21 Permanent atrial fibrillation

I48.3 Typical atrial flutter

I48.4 Atypical atrial flutter

I48.91 Unspecified atrial fibrillation

I48.92 Unspecified atrial flutter


The User Guide is available at https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Non-Group-Health-Plans/NGHP-User-Guide/NGHP-User-Guide. If you have any questions about these changes to the User Guide or any other issues related to Section 111 reporting, please let us know and we will be happy to help.


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