Recent Changes to Section 111 Reporting Requirements

New Criteria for Reporting ORM

Chapter III, Section 6.3 of the User Guide now provides: “The trigger for reporting ORM is the assumption of ORM by the RRE, which is when the RRE has made a determination to assume responsibility for ORM and when the beneficiary receives medical treatment related to the injury or illness. Medical payments do not actually have to be paid, nor does a claim need to be submitted, for ORM reporting to be required. The effective date for ORM is the DOI, regardless of when the beneficiary receives the first medical treatment or when ORM is reported.”

Previously, the User Guide stated that reporting ORM is required “when the RRE has made a determination to assume responsibility for ORM, or is otherwise required to assume ORM—not when (or after) the first payment for medicals under ORM has actually been made.” It is unclear how the new guidance applies in situations when the RRE is not aware that the beneficiary has received treatment. CMS will hopefully provide clarification in the near future.

Clarification of ORM Termination Dates Based on Physician Statements

The User Guide provides that “an RRE 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.” CMS has revised Chapter III, Section 6.3.2 of the User Guide to provide the clarification below for what date to report when reporting termination of ORM based on a physician statement.

• Where the physician’s statement specifies a date as to when no further treatment was required, that date should be the reported ORM termination date;

• Where the physician’s statement does not specify a date when no further treatment was required, the date of the statement should be the reported ORM termination date;

• Where the physician’s statement does not specify a date when no further treatment was required, nor is the statement dated, the last date of the related treatment should be used as the ORM termination date.

Reporting NOINJ Now Optional

The NOINJ code applies in “liability situations where a settlement, judgment, award, or other payment releases medicals or has the effect of releasing medicals, but the type of alleged incident typically has no associated medical care and the Medicare beneficiary/injured party has not alleged a situation involving medical care or a physical or mental injury.” Previously, reporting NOINJ was required in such situations. The new User Guide confirms that reporting NOINJ is now optional. Chapter IV, Section 6.2.5.2 of the User Guide provides: “In cases where the reporting of a liability record only meets the criteria for reporting a ‘NOINJ’ diagnosis code in Field 18, the reporting of the record is no longer required. However, it is optional for the RRE to report the record with the ‘NOINJ’ diagnosis code….”

Changes to NGHP Unsolicited Response File Format

As a reminder, beginning July 2023 RREs will be able to opt in to receive a monthly Unsolicited Response File for ORM records, which will show changes to ORM records made by an entity other than the RRE. The User Guide states that “[t]he only entity other than the RRE who can update these records is a BCRC CSR/Analyst on behalf of the (verified) beneficiary, for an access to care issue.” The new User Guide reflects changes that have been made to simplify the response file format and add file name formats.