NGHP User Guide Version 5.2 Released
Heather Sanderson
January 11, 2017

CMS has released an updated Non-Group Health Plan (NGHP) User Guide version 5.2. It can be found here. There is only one minor change to the User Guide, which is to reflect the new thresholds for workers’ compensation, liability and no-fault claims which CMS had announced back in November. For our prior blog on the updated thresholds which were announced in November, click here.

Specifically, the text of the change in the Updated User Guide version 5.2 states the following with respect to the new thresholds: For Section 111 reporting, the Centers for Medicare & Medicaid Services (CMS) has changed the minimum reportable Total Payment Obligation to the Claimant (TPOC) amounts for liability insurance (including self-insurance), no-fault insurance, and workers’ compensation claims, as follows: Liability is changing from $1000 to $750 for TPOC Dates of 1/1/2017 and subsequent. No-Fault is changing from $0 to $750 for TPOC Dates of 10/1/2016 and subsequent. Workers’ Compensation (WC) is changing from $300 to $750 for TPOC Dates of 10/1/2016 and subsequent. TPOC amounts that exceed these thresholds must be reported. However, TPOC amounts less than the specified threshold may be reported and will be accepted. The logic for the CJ07 error has been changed such that a TPOC of any amount will be accepted for all types of TPOCs, including liability TPOCs. The CJ07 error will continue to 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.

We will continue to provide updates on the User Guide and MMSEA Section 111 updates as they arise.



Heather Schwartz Sanderson, Esq., MSCC, CHPE, CLMP, CMSP

Chief Legal Officer

Franco Signor LLC