No-Fault Insurance Does Not Pay

30.2.1.1 - No-Fault Insurance Does Not Pay (Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23) If the services are related to an accident and the no-fault insurance has been billed but does not make payment because the individual's no-fault benefits are exhausted or, the individual's coverage expired, the beneficiary does not have an ORM record, and no other primary payers to Medicare have been identified, the provider may bill Medicare. A/B MACs and DME MACs will need to look at the statements from the no-fault insurer or the CAS segment and paid amount loop for electronic claims (paid amount loop on the 837 should show zero dollars paid by the NGHP insurer), or attached RA for hardcopy claims, to determine whether benefits were exhausted, coverage expired or services were not related to the accident/incident to process the claim appropriately. A/B MACs and DME MACs may send an ECRS request to the MSP Contractor to close the MSP record as deem necessary. When billing Medicare where no-fault insurance has been billed but does not make payment, annotate the date on which the other payer denied the claim and the reason for denial. If the provider later receives payment from no-fault insurance, it refunds the Medicare payment by submitting an adjustment bill for Part A and/or a reopening, or appeal request, for Part B. Part A providers notify the A/B MACs (Part A) of a No-Fault denial using occurrence code 24 (Date Insurance Denied) and indicate the date on which the other payer denied the claim. The reason for denial is indicated in remarks. In addition, the following occurrence codes are used to identify the date of the accident: 01 - Auto Accident and Date 02 - No-Fault Insurance Involved-Including Auto Accident/Other and Date If the conditions described in Pub. 100-05, Chapter 7 are met, conditional payments may be made. To request a conditional payment, providers enter value code 14 with zero value in form locator (FL) 39-41 to indicate the type of other insurer and that conditional payment is requested. The identity of the other payer is shown on line A of FL 50, and the identifying information about the insured is shown on line A of FL 58-62. The provider enters the proper occurrence code in FL 31-36 and the address of the insurer in FL 38 or Remarks (FL 80). In addition, an explanation of why the conditional payment is justified is shown in Remarks (FL 80). (See Pub. 100-05, Chapter 7 for an explanation of policy and procedures for conditional payment situations for contested, delayed, or no-fault claims.)