The Latest Gift from CMS: Updated Section 111 User Guide


12/29/2017

Like clockwork, count on the Centers for Medicare & Medicaid Services (CMS) to issue new guidance either around the Fourth of July or Christmas.  This year is no different, as CMS released an updated NGHP Section 111 Reporting User Guide earlier this week.  The changes are not earth-shattering, but are more substantive than the last several updates.

ORM Termination Policy Refinements

Perhaps the most noteworthy component to the User Guide update is that CMS has created a brand new section clarifying its policy around ORM Termination.  The new Section 6.3.2 of the Policy volume of the User Guide (Volume 3) reiterates the longstanding policy that ORM should not be terminated "as long as the ORM is subject to reopening or otherwise subject to an additional request for payment."  However, the User Guide provides slightly new language around additional circumstances where an ORM Termination can be reported.  The first of these is the most noteworthy:

"Where there is no practical likelihood of associated future medical treatment, an RRE may submit a termination date for ORM if it maintains a statement (hard copy or electronic) signed by the beneficiary’s treating physician that no additional medical items and/or services associated with the claimed injuries will be required."

What it Means

The real difference in this language is that an RRE can report ORM Termination if they "maintain" a statement in "hard copy or electronic" form that no additional medical items or services associated with the injuries will be required.  The "signed" statement from a treating physician is one of the more under-utilized components in Section 111 reporting.  By clarifying that the RRE can utilize this option when "there is no practical likelihood" of future medical treatment, CMS may be opening the door to increased use of this option. 

ORM termination is more critical now than ever, with the Commercial Repayment Center (CRC) pursuing rolling recovery on behalf of CMS.  The User Guide keeps similar guidance, largely unchanged, in the Technical chapter.

In addition, the new section on ORM Termination adds that:

"Where the insurer’s responsibility for ORM has been terminated under applicable state law associated with the insurance contract; [and] Where the insurer’s responsibility for ORM has been terminated per the terms of the pertinent insurance contract, such as maximum coverage benefits."

These "clarifications" simply confirm guidance that the industry has relied upon for the last several years.  Essentially, if a state law or contract terms limit an insurer or self-insured's obligation to pay for medical treatment, the RRE can file an ORM termination date effective with the particular state law or insurance contract. These would impact time-frames whereby an RRE’s obligation would end (i.e., statute of limitations or no-fault time limits).  The bottom line here is that most RREs will already be terminating ORM when these contractual or legal limits are reached, but the clarification is welcome.

Recap: MBI Effective Date April 2018 and Reporting Implications

As anticipated, almost all of the updates relate to technical and labeling changes associated with CMS' New Medicare Number project.   Federal law signed into law in 2015 requires Medicare to eliminate social security numbers as the basis for the Medicare Health Insurance Claim Number by April 2019.  Medicare is phasing out HICNs and replacing them with unique eleven digit Medicare Beneficiary Identifiers (MBIs).  The good news for those handling workers' compensation, no-fault, and liability claims is that Medicare Secondary Payer processes are exempt from exclusive use of the MBI. 

The MBI will be phased into use beginning in April 2018 and ending in April 2019.  The User Guide updates confirm that Responsible Reporting Entities and agents will be provided the MBI in all Section 111 reporting response files (including query files).  Beginning in April 2018, query files will begin to see a combination of HICNs and MBIs so RREs and agents will need to be capable of distinguishing between the two and identifying claimants accordingly. It's important to note that the RRE will still be able to utilize the SSN in the query process (full or partial), as well as in Section 111 reporting, indefinitely. 

The other anticipated announcement contained in the User Guide is that written correspondence from Medicare contractors will provide the MBI as soon as it is available on an individual claim, beginning in April 2018.  This is a natural outgrowth of the project and replaces the HICNs that are currently provided in correspondence from the Benefits Coordination and Recovery Contractor (BCRC) and the Commercial Repayment Center (CRC).

The User Guide update explains that for RREs who utilize the Direct Data Entry program established by CMS for low-volume reporting, they will be able to report and/or query utilizing either the HICN, SSN or MBI as the key identifier for individual claimant.

Conclusion

The User Guide's changes are more substantive than the last several updates.  Most noteworthy is the additional clarification around ORM Termination.  The clarification does not solve the core issue, however.  Current CMS policy imposes never-ending ORM in situations where an RRE cannot get a "signed statement" from a treating physician and the state-law or contractual opportunity does not exist.  We'd continue to invite CMS to update the ORM termination policies to more clearly offer a termination option in states like Michigan where lifetime no fault perpetuates the obligation to query and report often long-gone, hard-to-find, closed claims.

ExamWorks Clinical Solutions Section 111 Mandatory Insurer Reporting clients will see no major substantive changes to Section 111 reporting from these updates.  We will continue to work with our clients to address any changes that may occur, but do not anticipate any substantive technical complications from these announced changes.  If you have questions about the new Medicare card project, contact the MIR Service team at mirservice.support@examworks-cs.com.  For questions about ORM termination, please contact Marty Cassavoy at 781-517-8085 or marty.cassavoy@examworks-cs.com.

 

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