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New Section 111 Reporting User Guide Published by CMS (But No New Information Provided on Penalties for Noncompliance)
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New Section 111 Reporting User Guide Published by CMS (But No New Information Provided on Penalties for Noncompliance)

On October 1, 2018 the Centers for Medicare & Medicaid Services (CMS) published a new user guide for entities in the Non Group Health Plan (NGHP[1]) category, regarding Section 111 Mandatory Insurance Reporting under the Medicare Secondary Payer Act’s (MSP)[2] amendment called the Medicare, Medicaid, and SCHIP[3] Extension Act of 2007 (MMSEA). The MMSEA reporting obligations are commonly referred to as Section 111 Reporting or simply Section 111 because they were listed in Section 111 of the Public Law amendment to the MSP[4]. Section 111 requires NGHP entities or in some cases, Third Party Administrators for NGHP entities, as Responsible Reporting Entities (RREs), to report data to CMS about injury claims. The reporting which must be electronically transmitted, is sent to CMS through its Benefits Coordination & Recovery Center (BCRC) contractor, and includes a large amount of information identifying Medicare beneficiaries, their injuries, their legal representatives, dates of injury, dates of payment, whether injury-related payments are ongoing or are paid in lump sums etc., provided the annually updated dollar threshold for reporting (currently $750 for accident or exposure cases) is met.

The updated MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers’ Compensation USER GUIDE (Section 111 User Guide) is now in version 5.4.

Only two changes were announced in the new version of the Section 111 User Guide. The first change was the addition of an updated Paperwork Reduction Act disclosure and the second change was an update to the contact protocol for the Section 111 data exchange escalation process. The updated contact protocol is listed in its entirety below:

8.2 Contact Protocol for the Section 111 Data Exchange
In all complex electronic data management programs there is the potential for an occasional breakdown in information exchange.
If you have a program or technical problem involving your Section 111 data exchange, the first person to contact is your own EDI Representative at the BCRC. Your EDI Representative should always be sought out first to help you find solutions for any questions, issues or problems you have. If you have not yet been assigned an EDI Representative, please call the EDI Department number at 646-458-6740 for assistance.

Escalation Process

The CMS and the BCRC places great importance in providing exceptional service to its customers. To that end, we have developed the following escalation process to ensure our customers’ needs are met. It is imperative that RREs and their reporting agents follow this process so that BCRC Management can address and prioritize issues appropriately.

1. Contact your EDI Representative at the BCRC. If you have not yet been assigned an EDI Representative, please call the EDI Department number at 646-458-6740 for assistance.

2. If your Section 111 EDI Representative does not respond to your inquiry or issue within two business days, you may contact the EDI Director, Angel Pagan, at 646-458-2121. Mr. Pagan’s email is apagan@ehmedicare.com.

3. If the EDI Director does not respond to your inquiry or issue within one business day, you may contact the BCRC Project Director, Jim Brady, who has overall responsibility for the EDI Department and technical aspects of the Section 111 reporting process. Mr. Brady can be reached at 646-458-6682. His email address is JBrady@ehmedicare.com. Please contact Mr. Brady only after attempting to resolve your issue following the escalation protocol provided above.

When initially enacted on December 29, 2007, the enforcement clause under 42 U.S.C. §1395y(b)(8)(E) announced that applicable plans “shall be subject to a civil money penalty of $1,000 for each day of noncompliance with respect to each claimant.” That clause was changed with the SMART Act amendment to the MSP on January 10, 2013, effective at the beginning of 2014, to the phrase “may be subject to a civil money penalty of up to $1,000 for each day of noncompliance with respect to each claimant.” In this same 2013 SMART Act MSP amendment, an additional paragraph was added requiring the Secretary of the U.S. Department of Health and Human Services (Secretary) to publish a notice in the Federal Register soliciting proposals during a 60-day period, specifying practices by which enforcement sanctions would or would not be imposed under subparagraph (E). After proposals were to be submitted and considered, the Secretary, in consultation with the Attorney General, and after a 60-day comment period, was to publish in the Federal Register proposed specified practices for which enforcement sanctions will and will not be imposed and to later issue final rules specifying applicable enforcement practices. About a year after the SMART Act amendment was enacted, CMS sought comment through an advanced notice of proposed rulemaking (ANPRM) for the types of practices that would or would not result in civil money penalties, along with other related questions.  Final rules have still not been announced.

CMS wants “clean data” to be reported through Section 111 and has a process in place to test and reject reporting that does not meet CMS’ data quality rules.  How and when penalties for noncompliance with Section 111 will really be enforced will likely not be answered until CMS, through the Secretary of HHS, takes the required regulatory steps of issuing final rules on the subject.  Therefore, while most insurance companies and TPAs have set up internal systems to comply with Section 111, or paired with reporting agent vendors to help them comply, there is still time for Responsible Reporting Entities to establish a system to report Section 111 data without fear of reprisal.

Interestingly, another SMART Act initiative is now in its final stages of completion.  That initiative has been the gradual removal of Social Security Numbers from Medicare ID numbers through the replacement of the SSN-based Health Insurance Claim Number (HICN) with a new non-SSN-based Medicare Beneficiary Identifier (MBI).  CMS has estimated this project to be completed by April 2019.  It has mailed almost 35 million new Medicare cards to date with a majority of seven total “waves” of mailing completed. Will CMS begin tackling the reporting conundrum next? While companies doing reporting may still use the HICN and are not yet required to use the MBI in Section 111 Reporting, it would be wise for companies to plan ahead and ready themselves for transmission of the new MBI format Medicare ID in the future.


[1] Entities in the NGHP category include Liability Insurance (including Self-Insureds), Workers Compensation Plans, and No-Fault Insurance.

[2] 42 U.S.C. § 1395y(b)(2) et seq.

[3] SCHIP stands for State Children’s Health Insurance Program

[4] Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) (P.L. 110-173, Title I, §111(a)), found within the MSP at 42 U.S.C. § 1395y(b)(8).

 

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