CMS Releases NGHP User Guide 8.2
On November 18, 2025, the Centers for Medicare & Medicaid Services (CMS) published Version 8.2 of the MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting Liability Insurance (including Self-Insurance), No-Fault Insurance, and Workers’ Compensation User Guide (NGHP User Guide).
Section 6.5.1.3 of Chapter III was updated to include clarification on when it may be appropriate to submit multiple records for a single individual, most notably as it relates to Medicare Set Aside (MSA) and Total Payment Obligation to the Claimant (TPOC) reporting:
· Joint settlements, judgments, awards, or other payments – In a joint settlement situation, each RRE must report any responsibility it has for ongoing medicals on a policy-by-policy basis, without regard to the reporting or policy details of any other [Responsible Reporting Entity (RRE)]. An RRE may need to submit multiple records for the same individual depending on the number of policies at issue for an RRE, and/or the type of insurance or workers’ compensation involved. Where there are multiple defendants and they each have separate settlements with the plaintiff, the applicable RRE reports that separate settlement amount. For a settlement, judgment, award, or other payment with joint and several liabilities, each RRE must report the total settlement, judgment, award, or other payment—not just its assigned or proportionate share.
· Multiple settlements involving the same individual – If there will be multiple TPOCs submitted for the same individual, for the same incident, but reported by different RREs, the records shall reflect each RRE’s unique TPOC amount and not the aggregate TPOC the beneficiary will be receiving. If more than one RRE has assumed responsibility for ongoing medicals, Medicare would be secondary to each such entity.
· Single settlement resolving multiple incidents (different Dates of Incident) – Where there are multiple incidents (multiple dates of incident) being resolved with one TPOC, the RRE shall report the earliest date of incident and include all diagnosis codes being settled for all dates of incident. This applies regardless of the timing of the subsequent dates of incident, the nature of the injuries, or any allocation made to each date of incident in the settlement documents. This ensures that all medicals that were released by the settlement are accurately recovered while still affording the beneficiary a dispute and administrative appeal process if any claims are erroneously identified.
· Medicare Set-Asides – As it relates to multiple dates of incident, an MSA, if applicable, shall be reported under the same guidance as above. That is, the earliest date of incident, if only one TPOC is made. If multiple TPOCs are submitted, but only one MSA is reported, the MSA shall be reported on the first TPOC only. Where there are multiple defendants (RREs) reporting in this scenario, the same guidance applies to MSAs as it does to TPOCs.
· Med Pay and Personal Injury Protection (PIP) are both considered no-fault insurance by CMS (Field 58, Plan Insurance Type = ‘D’). RREs must combine PIP/Med Pay limits for one policy when they are separate coverages being paid out on claims for the same injured party and same incident under a single policy and not terminate the ORM until both the PIP and Med Pay limits are exhausted. If PIP and Med Pay are coverages under separate policies, then separate records with the applicable no-fault policy limits for each should be reported.
Sanderson Firm Commentary
On April 4, 2025, Responsible Reporting Entities (“RREs”) were left stranded with little guidance when the mandatory reporting of workers’ compensation MSA (“WCMSA”) amounts through Section 111 reporting went live. Between the communications freeze that began this year and the recent Government shutdown, RREs spent much of 2025 with more questions than answers surrounding reporting nuances in global settlement scenarios.
CMS rolled out the April 4, 2025, reporting requirements despite having been cautioned repeatedly by industry groups and stakeholders about foreseeable downstream consequences, including with respect to this crucial global settlement approach and the errors that would result, in some cases causing delays in settlement reporting. CMS’ failure to truly appreciate these warnings, and its ensuing lack of communication caused much frustration and concern across the industry. Rightly so, as the first Civil Money Penalty (“CMP”) audits swiftly approach in Q1 of 2026. (Read more about CMPs here.)
In the absence of appropriate CMS guidance, a wide range of temporary approaches were adopted by RREs. Some chose to report the same TPOC/MSA amount for all claims and others reported different TPOCs for each claim based on how payments had been split across the multiple claims being settled and only included the MSA data on one claim.
This updated guidance from CMS provides RREs with some clarification, however, there is still likely to be objections to some of the proposed solutions, especially for situations where there is one MSA and multiple defendants as CMS advises that one party should report the MSA on the earliest DOI in multiple DOI settlements.
It remains unclear how RREs should approach multiple defendant single DOI settlements, if we draw the conclusion that they want all parties to report the full TPOC and MSA; we are still left with questions about whether the reporting errors caused by multiple parties submitting the same MSA information have been resolved. If, ultimately, the solution to this problem is that only one party reports the MSA, then the industry may object as it is unlikely parties want to leave this compliance issue in the hands of their co-defendants.
Other Updates
There were also updates to Chapter IV – Technical Information to correct the number of days required to generate a response file for claim files from 48 to 33 and to add new reason codes to Table 7-4 noting that beginning April 2026, new reason codes will be available to further improve granularity and clarity of updates to MSP and drug coverage records.
Finally, in Chapter V –Appendices, the definitions of field 43 of the Claim Input File Detail Record table and CW09 of the Claim Response File Error Code Resolution table have been expanded for clarification and CMS updated Appendix B ang G to note the Recovery Agent TIN field is required if agent name is submitted.
CMS also published a separate alert regarding conditional payment recovery and mandatory insurer reporting thresholds for certain liability, no-fault and workers compensation settlements confirming that they will maintain the current $750 threshold:
As required by section 1862(b) of the Social Security Act, the Centers for Medicare and Medicaid Services (CMS) is required to review the costs related to collecting Medicare’s conditional payments and compared this to recovery amounts. Until further notice, the threshold for physical trauma-based liability insurance settlements will remain at $750. Until further notice, CMS will also maintain the $750 threshold for no-fault insurance and workers’ compensation settlements, where the no-fault insurer or workers’ compensation entity does not otherwise have ongoing responsibly for medicals.
This means that entities are not required to report, and CMS will not seek recovery on settlements, as outlined above. Please note that the liability insurance (including self-insurance) threshold does not apply to settlements for alleged ingestion, implantation, or exposure claims.
The $750 threshold has now been in place for a decade and based on the wording change in this year’s alert which states “[u]ntil further notice” instead of noting a specific year, CMS may have no plans of changing the threshold amount any time soon, or CMS could be taking in the commentary from industry stakeholders such as the MARC Coalition who have been urging an increase to this threshold. While CMS may not be ready to adjust the numbers yet, perhaps we will see an update occur sooner than a year from now. In previous years CMS included a link in the alert to the annual report to Congress on the methodology used to determine the threshold, but no link was provided this year. It does not appear that this report has been published yet, but it will be interesting to see what factors CMS considered when calculating the average cost of recovery per case.
Lastly, CMS has published an updated ICD-9 and ICD-10 diagnosis code lists for 2026 located here: cms.gov/medicare. The updated lists contain both valid and excluded ICD-9 and ICD-10 diagnosis codes that may be used effective immediately.
If you have questions regarding the CMS’ NGHP User Guide update, $750 reporting threshold, or Sanderson Firm’s Section 111 reporting and audit solutions, please contact us.
