Medicare Secondary Payer Section 111 Reporting Program

A Medicare Secondary Payer Section 111 reporting program is the written set of owners, calendar, claim-screening rules, response-file log and agent-oversight file that lets a liability insurer, no-fault insurer, workers' compensation plan or self-insured organization report Medicare beneficiary claims to CMS on time and show that it did. Integral Healthcare Solutions (IHS) drafts that program for the reporting entity's leaders to adopt. The governing text is the CMS NGHP User Guide, version 8.6, dated October 5, 2026.

IHS is a consulting firm, not a law firm. Your counsel decides whether you are a responsible reporting entity and what you must report.

Last updated: November 2026

What is Medicare Secondary Payer Section 111 reporting?

Section 111 reporting is a federal duty under 42 U.S.C. 1395y(b)(8) (statute text, govinfo, 2023 edition, page opened 2026-11-05). The statute requires an applicable plan to determine whether a claimant is entitled to Medicare benefits and, if so, to submit the claimant's identity and other information the Secretary specifies, in a form and manner, including frequency, that the Secretary specifies. It defines the applicable plan as the following laws, plans or other arrangements, "including the fiduciary or administrator for such law, plan, or arrangement": liability insurance (including self-insurance), no-fault insurance, and workers' compensation laws or plans.

CMS calls an organization that must report a responsible reporting entity, or RRE. On its Mandatory Insurer Reporting (NGHP) page (page opened 2026-11-05), CMS says: "In general terms, NGHP RREs include liability insurers, no-fault insurers, and workers' compensation plans and insurers."

CMS calls the NGHP User Guide "your primary source for Section 111 reporting requirements" (page opened 2026-11-05). This page uses version 8.6 chapters Registration Procedures, Policy Guidance and Technical Information (pages opened 2026-11-05). CMS says its alerts supersede information published in the guide.

In short, Section 111 reporting is a standing cycle: determine RRE status, register, identify reportable claims (ongoing responsibility for medicals, called ORM, and settlements, judgments, awards or other payments, called TPOC for total payment obligation to the claimant), submit each quarter in the assigned seven-day window, work the response file, and stay inside CMS's one-year timeliness clock.

Who needs a Section 111 program and what triggers it?

An organization that pays or administers liability, no-fault or workers' compensation claims for people who may be Medicare beneficiaries needs a routine for this cycle, and the first question is which legal entity is the RRE. CMS's guide says that where an entity engages in a business, trade or profession, deductible amounts are self-insurance for Medicare Secondary Payer purposes, but where an insurer is responsible for Section 111 reporting on the policy, the insurer reports the deductible and any amount above it. It says a self-insurance pool is the RRE only if it is a separate legal entity, has full responsibility to resolve and pay claims with pool funds, and pays them without review or approval authority held by the participating members, and the pool is also the RRE where the statute authorizing it requires it to be licensed and regulated in the same manner as liability insurance (or workers' compensation, where applicable).

• A workers' compensation settlement is reached on or after April 4, 2025. CMS requires the amount of any Workers' Compensation Medicare Set-Aside Arrangement created in the settlement to be reported.
• CMS publishes a new guide version. Version 8.6 updated its language on wrongful death settlements and on the Qualified Settlement Fund exception.
• CMS audit sampling began in January 2026. CMS selects 250 records each quarter from accepted new Section 111 records and from records Medicare received outside Section 111, not per RRE, and writes to an RRE only when one of its records looks noncompliant (CMS, NGHP Civil Money Penalties, page opened 2026-11-05).

How does IHS help?

IHS turns the CMS reporting cycle into documents your claims and compliance teams follow every quarter. Thomas G. Goddard, JD, PhD, IHS founder and former URAC Chief Operating Officer and General Counsel, leads the work. IHS runs three practice lines, Accreditation Consulting, Compliance Services and Program Development. This work sits in Compliance Services.

The process

1. Gap assessment. IHS compares your routine with the statute, the CMS pages and the current guide.
2. Evidence mapping. IHS ties each step, registration, claim screening, submission, response handling and ORM termination, to a record.
3. Drafting. IHS drafts an RRE determination worksheet for counsel, a reporting calendar for your assigned window, a claim-screening procedure, an error and response-file log, an agent-oversight checklist and an evidence file.
4. Mock review. IHS reads the file against the guide and lists what is missing.

What you supply

You supply the items in the checklist below and the name of the person who runs each quarterly submission. Counsel decides who is the RRE and what must be reported.

The real limit

IHS does not register as or for an RRE, submit files, query beneficiary status or contact CMS. IHS drafts; your organization registers, reports and answers CMS.

What should you have ready?

1. Counsel's written decision on whether each legal entity is an RRE, with the corporate structure, deductible, self-insured retention and pool facts behind it (guide section 6.1).
2. Your RRE ID, registration record and current profile report, which shows your assigned submission window.
3. The name of your Authorized Representative and Account Manager. The guide says the Authorized Representative receives notifications from the Benefits Coordination and Recovery Center about non-compliance and cannot be an agent or a user of the Section 111 Coordination of Benefits Secure Website.
4. A list of claims where you have assumed ongoing responsibility for medicals, with the date of incident (guide section 6.3).
5. A list of settlements, judgments, awards and other payments, with the TPOC Date, the funding date and any court or commission approval date (guide sections 6.4 and 6.5.1.2).
6. Your agent or TPA contract and the reporting duties it assigns.
7. Prior response files, with the error codes and what was resubmitted, and your method for identifying Medicare beneficiaries.
8. For terminated ORM, the basis you relied on, such as a treating-physician statement on file (guide section 6.3.2).
9. Any CMS correspondence with its date of receipt, and the version of the guide and alerts your team works from today.

With the list in hand, the free introductory call is where IHS walks through it with you.

How do the ways of reporting compare?

CMS describes more than one way to report, and IHS sets them side by side without telling you which to use.

Group health plan reporting runs under a different subsection of the statute, 1395y(b)(7), and is not covered on this page.

What does it cost?

Three costs apply, and only one is an IHS fee. The first is exposure to CMS penalties, which depends on how late a record is. The regulation, 42 CFR 402.105(b)(3) (current text opened 2026-11-05), sets a per-day amount for each record reported more than one year after the settlement, judgment, award or other payment, including the effective date of the assumption of ongoing responsibility for medicals. CMS's penalty page counts that year from the later of the Settlement Date and the Funding Delayed Beyond TPOC Date. The amount steps up at one year, two years and three years late. It sets a maximum for noncompliance associated with any one individual, and both the daily amounts and the cap are adjusted annually under 45 CFR part 102. CMS says it issues penalties prospectively only, under a rule enforced since October 11, 2025. Check CMS for the current adjusted amounts.

The second cost is the IHS engagement. IHS scopes each engagement after a free introductory call.

The third is your own staff time, plus separate counsel time on the RRE question.

What this is not

• It is not legal advice. IHS is a consulting firm, not a law firm, and does not decide who is a reporting entity or how to respond to a CMS notice.
• It is not a guarantee of any outcome with CMS.
• IHS does not register for you, submit files or contact CMS. IHS drafts; your organization reports.

Frequently asked questions

Who has to report under Medicare Secondary Payer Section 111?

An applicable plan has to report. The statute defines it as liability insurance (including self-insurance), no-fault insurance, and workers' compensation laws or plans, including the fiduciary or administrator for each. CMS says RREs may also be organizations that are self-insured for those lines. Counsel decides which entity in your corporate structure is the RRE.

What is a responsible reporting entity?

An RRE is the organization that must report under Section 111. CMS's guide says an RRE may not shift its responsibility to report to an agent, by contract or otherwise, and remains solely responsible and accountable for complying with CMS instructions and for the accuracy of the data submitted.

What claims are reportable?

CMS's guide says information is reported where the injured party is or was a Medicare beneficiary and medicals are claimed or released, or the payment has the effect of releasing medicals. Two things trigger a record: the RRE's assumption of ongoing responsibility for medicals (ORM), and a settlement, judgment, award or other payment (a TPOC). Property-damage-only and indemnity-only settlements are not reported if they neither claim nor release medicals nor have that effect; a settlement that releases medicals or has that effect must be reported regardless of allocation.

Is there a dollar threshold for TPOC reporting?

As of January 1, 2026, CMS keeps a threshold of 750 dollars for physical-trauma-based liability settlements, and the same for no-fault insurance and workers' compensation where the no-fault insurer or workers' compensation entity does not otherwise have ongoing responsibility for medicals. A TPOC is reportable only if the cumulative TPOC amount exceeds the threshold. The threshold does not apply to alleged ingestion, implantation or exposure cases, where CMS says any settlement, regardless of amount, should be reported.

How often do we submit?

A file submitter sends a production Claim Input File each quarter, during the RRE ID's assigned seven-day window, unless the RRE ID has nothing to report that quarter. Direct data entry submitters follow a different clock: CMS's guide says they must report within 45 calendar days of the TPOC Date.

Can our TPA do the reporting for us?

A TPA or other agent can create and exchange the files, but it cannot register for the RRE and cannot be named the RRE's Authorized Representative. The RRE still answers for timeliness and accuracy. IHS drafts an agent-oversight checklist so the RRE can check each quarter's submission and response files.

What happens if CMS finds a late record?

CMS sends an Informal Notice, which assesses no penalty. The RRE has 30 days from receipt to submit mitigating evidence, and CMS says extensions will not be granted. If CMS upholds its finding, a Notice of Proposed Determination follows, and the RRE must request a hearing within 60 calendar days of receipt. Counsel handles the response; IHS drafts the evidence file behind it.

How current is this page?

It rests on NGHP User Guide version 8.6, dated October 5, 2026, and on CMS pages and federal text opened on November 5, 2026. CMS says alerts published after a guide version supersede information published in it, so check the CMS alerts page before you rely on any date or threshold here.