Incorrect GHP Primary Payments

10.5 - Incorrect GHP Primary Payments (Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23) A GHP may advise a provider, physician, or other supplier that the GHP believes that Medicare may be the proper primary payer for services for which the GHP had previously made a primary payment. The GHP may request that the provider, physician, or other supplier either submit an initial claim to Medicare or request that Medicare reopen its determination on previously submitted claims for the services. The normal Medicare timely filing and reopening rules apply to these situations. The initial claim must be submitted within the timely filing period. An initial determination on a previously adjudicated claim may be reopened for any reason for 1 (one) year from the date of that determination. After 1 (one) year and prior to 4 (four) years from the date of determination, “good cause” is required for Medicare to reopen the claim. In general, Medicare does not consider a situation where (a) Medicare processed a claim in accordance with the information on the claim form and consistent with the information in the Medicare’s systems of records and (b) a third party mistakenly paid primary when it alleges that Medicare should have been primary to constitute “good cause” to reopen. .