Provider, Physician, and Other Supplier Billing

30 - Provider, Physician, and Other Supplier Billing (Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23) If services are covered under an open GHP or related to an NGHP MSP accident or injury incident, bill the primary insurer first. There are situations where providers bill for services related to a new accident or injury that are not related to an existing NGHP MSP record found on HETS or CWF. Physicians, providers and suppliers may need to use the same diagnosis codes that are found on the NGHP record in HETS and CWF. You may submit these claims to Medicare after you submit these claims to the appropriate GHP and/or NGHP insurer. The NGHP insurer may deny these claims if the claim is not related to the original accident or injury or the case has not been settled. After you submit these claims to Medicare, Medicare may mistakenly deny these services because the diagnosis codes on the claim are related to the diagnosis codes found on the NGHP MSP record on HETS and CWF. Physicians, providers and suppliers may appeal the denied claim with your MAC. Physicians, providers and other suppliers must provide an explanation, or a reason code, to justify why the services are not related to the accident or injury on record. Nonetheless, physicians, providers and other suppliers must continue to see or provide services to the beneficiary if claims are mistakenly denied.