The Centers for Medicare and Medicaid Services (CMS) issued an updated Section 111 NGHP User Guide – Version 6.4, on June 11, 2021. CMS will now allow the termination of ORM if the following criteria are met.

Where there is no practical likelihood of associated future medical treatment, which is reflected by meeting ALL of the following:

  • No claims were paid with any diagnoses codes related to alleged ingestion, implantation, or exposure; and
  • No claims were paid, for any medical item or service related to the case, within five (5) years of the date of service of any such claim; and
  • Treatment did not include, nor were any claims paid related to, a medical implantation or prosthetic device; and
  • The total amount paid by the insurer, for all medical claims related to the case, did not exceed $25,000.

Note: If, at any time, any of the parameters set forth above should no longer be applicable, the insurer must then update the ORM record to reflect that they, once again, have ongoing responsibility for medicals (i.e., update the termination date to all zeroes). Should the case once again fall under these parameters (for example, if five years elapse from the last relevant date of service), then ORM for that case may once again be terminated in accordance with the criteria above. This will allow Responsible Reporting Entities to terminate ORM in older claims that have either already been administratively closed or are otherwise inactive, as long as all the criteria above are met.

Please contact Shannon Metcalf with questions regarding this update. She is a Medicare Set-Aside Certified Consultant (MSCC), whose practice focuses heavily on Medicare Secondary Payer Act compliance.

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Shannon P. Metcalf