We recently blogged regarding CMS releasing their updated NGHP User Guide version 5.3. The primary change outlined in the Summary of Changes in the User Guide was regarding CMS’ SSNRI initiative which will ultimately replace the use of SSN’s with MBIs. For more information, our prior blog can be found here.
It appears that CMS has also modified another section of the User Guide referencing standards for Ongoing Responsibility for Medical (ORM) termination, although this update was not outlined in the Summary of Changes section of the new User Guide. The new section is 6.3.2 and it states:
When ORM ends, the RRE should report the date that ORM terminated and should NOT delete the record. Please note that a TPOC amount is not required to report an ORM termination date. An ORM termination date should not be submitted as long as the ORM is subject to reopening or otherwise subject to an additional request for payment. An ORM termination date should only be submitted if one of the following criteria has been met:
- Where there is no practical likelihood of associated future medical treatment, an RREs 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;
- Where the insurer’s responsibility for ORM has been terminated under applicable state law associated with the insurance contract;
- Where the insurer’s responsibility for ORM has been terminated per the terms of the pertinent insurance contract, such as maximum coverage benefits.
Franco Signor Commentary: These ORM termination standards are not a change from CMS’ prior guidance on ORM termination. Essentially, the RRE can still only terminate ORM based upon the following conditions: 1) The parties are in receipt of a treating physician statement that no future medical care will be required; 2) The RRE is no longer responsible to pay for continuing medical treatment under state law; and 3) The RRE is no longer responsible to pay due to terms of the insurance contract (such as policy exhaustion).
However, what is interesting is that this guidance on ORM termination was not previously outlined in CMS’ prior NGHP User Guides; this is the first time that CMS has issued guidance on ORM termination in a formal manner, in the User Guide. The ORM termination standards guidance from CMS were only previously available in an ORM Training PowerPoint (it can be found here) or discussed verbally on prior CMS Section 111 Teleconferences.
By publishing ORM termination standards in its most formal policy, the NGHP User Guide, CMS is standing firm in its standards for Responsible Reporting Entities (RREs) to be able to terminate ORM. As we have discussed in a previous blog, administrative closure of a claim does not equal ORM Termination. If an RRE terminates ORM based upon administrative closure of the file or not based upon one of the three options that CMS has set forth in its User Guide, an RRE may be subjecting itself to penalties of up to $1000 per day/per claim. Our prior blog on this topic can be found here.
For more information on ORM termination and Section 111 best practices, please contact us at firstname.lastname@example.org.