CMS Issues Updated Section 111 NGHP User Guide


This week CMS released Version 5.6 of the Section 111 NGHP User Guide reflecting changes related to the PAID Act, technical updates involving claimants listed in Medicare’s system prior to their entitlement date, and additional general guidance concerning liability and no-fault cases when the date of incident is prior to December 5, 1980.


The User Guide reflects that the beneficiary lookup tool is now available to DDE submitters and offers submitters the ability to confirm the last three years of Medicare Advantage Plan and Medicare Prescription Drug Plan enrollment information for Medicare beneficiaries, as well as Medicare Part A and B entitlement dates. The User Guide also indicates that as of December 11, 2021, RREs will receive the last three years of Medicare Advantage Plan and Medicare Prescription Drug Plan enrollment information along with Part A and B entitlement dates through the query process. RREs will need to use Version 5.0 of the HEW software in order to receive such information. RREs may submit test query files using the new version of the HEW software prior to the December 11, 2021, implementation date.


The User Guide reflects that CMS now accepts claim input records submitted within three months of a claimant’s Medicare entitlement date if the claimant is in Medicare’s system but not yet a beneficiary. Often individuals will be listed in Medicare’s system a few months prior to their Medicare entitlement date. If the claimant is more than three months away from becoming a Medicare beneficiary, claim input records will be returned with an error code.


The User Guide was also revised to provide additional guidance regarding liability and no-fault claims with dates of injury prior to December 5, 1980. The User Guide now states that “In cases where exposure has ended prior to December 5, 1980, and there is not yet a settlement, judgment, award, or other payment, it would be inappropriate, and counter to the MMSEA Section 111 reporting obligations, to report such a claim.”


If you have any questions regarding Section 111 reporting requirements, please let us know. We will be happy to help.


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