Provider Billing Medicare for Secondary Benefits Where Services Are Covered

30.3 - Provider Billing Medicare for Secondary Benefits Where Services Are Covered by a GHP (Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23) If a GHP pays primary benefits, secondary Medicare benefits may be payable to supplement the amount paid by the GHP. Medicare secondary benefits may be payable if the following situations apply: • The plan payment is less than the provider's charges for Medicare covered services; • The plan payment is less than the gross amount payable by Medicare; and, • The provider does not accept and is not obligated to accept the GHP primary payment as payment in full. When a provider bills Medicare for secondary benefits, the primary payment amounts are reported according to sections 40.1.1 - 40.1.2 below. If a GHP denies a claim for primary benefits, the provider submits a bill for conditional primary benefits with an explanation of any reason given by the plan for its denial. For an inpatient hospital or SNF stay, if the GHP's payment equals or exceeds the gross amount payable by Medicare, or equals or exceeds the provider's charges for Medicare covered services or the provider accepts or is obligated to accept the GHP payment as payment in full, a no payment bill is submitted in accordance with Pub. 100-05, Chapter 5. Any excess of the GHP payment over the gross amount payable by Medicare is not deducted from the provider's Medicare reimbursement at final cost settlement. If the GHP denies a provider's claim for primary benefits, the provider submits a claim for primary Medicare benefits or conditional primary benefits as provided for in Pub. 100-05, Chapter 5.