CMS Releases Latest Version of the MMSEA Section 111 NGHP User Guide: Overview and Analysis
Katie Fox
January 10, 2015

In further implementation of the SMART Act, on January 5th, 2015 CMS released the latest version of the MMSEA Section 111 NGHP User Guide. The changes were expected, and are welcomed. The 2 major changes to the user guide are outlined below:

1) CMS will now accept 5 digit SSN’s on submitted records. RREs that submit query and claim input files may now enter SSN’s with 4 leading spaces. DDE clients only need to type in the last 5 and do not need to enter the leading spaces. To accommodate this change CMS has updated the Disposition Codes to include DP (used for identifying duplicates), Disposition Code 51 has been slightly modified, and the beneficiary matching logic has been modified. Taken directly from the user guide:

a. The beneficiary matching logic has been changed. First, an exact match on the HICN or SSN entered (either the last 5 digits or full 9 digits) must be found. Then, at least three of the four remaining data elements (listed below) must be exactly matched to the individual:

First initial of the first name
First six characters of the last name
Date of Birth (DOB)

2) The Lower Limit Threshold for Liability TPOC’s was raised from $300 to $1000 for TPOC reporting of liability cases. Liability insurance (including self-insurance) claim reports with no ongoing responsibility for medicals (ORM) and cumulative TPOC amounts less than or equal to $1,000 will reject with a CJ07 error if the most recent TPOC date is October 1, 2014 or after.

For Franco Signor clients utilizing our MIR reporting solutions we are currently able to process claim input files with the new SSN changes and we are reporting files at the new threshold. For any organization having difficulty capturing the full SSN the option to capture the last five digits and prefill with zeros for the earlier four digits should be beneficial.

As for the increase in the lower limit for liability TPOCs the increase from $300 to $1000 should be beneficial to both the Medicare beneficiary and the industry.

If you have any questions about how these changes affect your compliance, please feel free to contact Franco Signor.