NGHP User Guide 5.0 Released Today
Heather Sanderson
September 16, 2016

The Centers for Medicare and Medicaid Services released an update to the Non-Group Health Plan (NGHP) User Guide with minor changes to chapters IV and V of the document. This revision – version 5.0 of the User Guide – is dated July 11, 2016 but was published on the CMS website on July 26, 2016.

The changes to the document include the following areas:

  • Claim response file error code CI25 has been corrected to display properly (was previously shown as “C125”) in Table F-4 of Chapter 5.
  • The possible causes for claim response file error codes CR65 and CR85 have been updated. For both of these errors, the validation logic confirms that the claimant 3 representative TIN and claimant 4 representative TIN are not the same as the TIN supplied in the claim input record for the applicable plan – field 52.  The possible error causes for these fields are now aligned with the claimant 1 and 2 representative TIN logic, which already included that validation. These changes are also included in Table F-4 of Chapter 5.
  •  Compliance flag codes 01 and 03 have been updated so that file receipt date is used instead of the current file submission period in relation to the 135 day measurement against TPOC dates and ORM termination dates supplied in the claim record.

The change to the compliance flag date calculations should have a positive impact for Responsible Reporting Entities (RREs). It allows for flexibility and accuracy in calculating the 135 day submission requirement for TPOCs and ORM termination.

The new NGHP User Guide 5.0 can be found here.