Medicare General Information, Eligibility and Entitlement Manual (Pub. 100-01), Ch. 5 § 10.1.8
Medicare Secondary Payer Involvement of Failure to File
10.1.8 - Medicare Secondary Payer Involvement of Failure to File
Proper Claims
(Rev. 1, 09-11-02)
This section is a further explanation of §10.1.1.
A provider that has not filed a proper claim and has received a reduced payment because
of this from a payer primary to Medicare agrees:
•
To bill Medicare for an amount no greater than would have been payable as
secondary payment if the primary insurer's payment had been based on a proper
claim; and
•
To charge the beneficiary only (a) the amount it would have been entitled to
charge if it had filed a proper claim and received payment based on such a claim;
and (b) an amount equal to any third-party payment reduction attributable to
failure to file a proper claim, but only if the provider can show that:
o It failed to file a proper claim solely because the beneficiary, for any
reason other than mental or physical incapacity, failed to give the provider
the necessary information; or
o The beneficiary, who was responsible for filing a proper claim, failed to
do so for any reason other than mental or physical incapacity.