Changes to Section 111 TPOC Reporting Thresholds


On December 12, 2016, CMS issued an Alert regarding changes in the Section 111 TPOC reporting threshold for liability, no-fault and workers' compensation claims. The Alert provides:

  • Liability Insurance: The mandatory reporting threshold for liability insurance (including self-insurance) Total Payment Obligation to the Claimant (TPOC) Amounts dated January 1, 2017 or after is changing from $1000 to $750. If the most recent TPOC Date is on or after January 1, 2017, and the cumulative TPOC Amount is greater than $750, the TPOC(s) must be reported.

  • No-Fault Insurance: The mandatory reporting threshold for no-fault insurance TPOC Amounts dated October 1, 2016 or after changed from $0 to $750. If the most recent TPOC Date is on or after October 1, 2016, and the cumulative TPOC Amount is greater than $750, the TPOC(s) must be reported.

  • Workers’ Compensation: The mandatory reporting threshold for workers’ compensation TPOC Amounts dated October 1, 2016 or after changed from $300 to $750. If the most recent TPOC Date is on or after October 1, 2016, and the cumulative TPOC Amount is greater than $750, the TPOC(s) must be reported.

  • Reporting of cumulative TPOC Amounts at or below the required reporting threshold will be accepted but are not required. As of January 1, 2017, the CJ07 error code logic will be updated to no longer reject TPOC amounts less than the required reporting thresholds. Until that time, workers’ compensation TPOCs of less than or equal to $300 and liability TPOCs of less than or equal to $1000 will be rejected unless reported with ORM. After January 1, 2017, the CJ07 error will only be returned for a liability, workers’ compensation, or no-fault claim report where the ORM Indicator is set to “N” and the cumulative TPOC Amount is zero.

On January 3, 2017, CMS issued an updated Section 111 NGHP User Guide (version 5.2) incorporating the changes to the TPOC reporting thresholds. The User Guide was also updated to reflect that the CJ07 error code will only be returned if the ORM Indicator is set to "N" and the cumulative TPOC amount is $0.00.

The Alert is available here.

The updated User Guide is available here.


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