Generating Unsolicited Responses to the VA

1.3 - Generating Unsolicited Responses to the VA (Rev. 1454, Issued: 02-22-08, Effective: 04-01-08, Implementation: 04-07-08) While the VA is entitled by law to collect the coinsurance and deductible amounts that would have been payable had the claim been a true Medicare claim, it is generally permitted to do so only to the extent that there are no true Medicare claims for coinsurance and deductible submitted to the insurer for the same beneficiary for the same year. While the VA submits these Medicare-equivalent claims in good faith, based on the current deductible information within CWF and maintained by the shared systems, situations sometimes arise where a true Medicare claim is subsequently adjudicated and for whom the insurers' payment of deductible is owed. When this occurs, and the supplemental insurer processes the true Medicare claim, it may deny the claim believing it has already paid the deductible, with the possible result of providers in turn billing the Medicare beneficiary for this amount. While the VA is willing to pay back the amounts it collected in error, it will not always know that this situation has occurred, and has asked Medicare to help it determine when this situation has transpired. The solution is an unsolicited response, sent to the VA, indicating that a change in Medicare deductible has occurred since the adjudication of the VA claim. The unsolicited response will show the amount of deductible approved for the affected VA claim and the total true Medicare deductible satisfied as of the date the Medicare claim was adjudicated. There will be one unsolicited response per affected VA claim. The unsolicited responses will be generated each time a Medicare claim affecting the deductible is adjudicated after the adjudication of a VA claim applying a deductible for the same year of service, even if the VA claim has not overapplied the deductible. Although this provision became effective January 1, 2006, it affects claims with dates of service January 1, 2004, and later.