Annotation of Claims Denied by GHP's, Liability or No-Fault Insurers

40.3 - Annotation of Claims Denied by GHP's, Liability or No-Fault Insurers (Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23) Primary Medicare benefits that are paid (if the beneficiary is not appealing the GHP denial) when a single or a multiple employer plan for which CMS has approved the plan’s multi- employer exemption request denies a claim for primary benefits because: • The beneficiary is age 65 or over and is enrolled in a single employer plan of an employer who does not employ 20 or more employees; • The beneficiary is age 65 or over and is enrolled in a multi-employer plan by virtue of employment with an employer that does not employ 20 or more employees and the plan has elected the small employer exception; • The beneficiary is not entitled to primary benefits under the plan; • The beneficiary is under age 65 and disabled and the employer does not employ 100 or more employees and the employer is not a member of a multiple employer GHP which has at least one employer that employs 100 or more employees; • The beneficiary is not entitled to benefits under the plan on the basis of rules that apply equally to all participants without regard to age or Medicare entitlement; • Benefits under the GHP are exhausted for the services involved; • The services are not covered by the GHP under any circumstances for any covered individual; • The beneficiary has Medicare based on ESRD (under age 65 and eligible based on ESRD) and not in a Medicare coordination period. Medicare does not pay primary Medicare benefits if it is believed that the GHP covers the particular service and the plan asserts that the services are not covered for “primary payment” when provided to Medicare beneficiaries. Where a GHP denies payment for any of these reasons, the provider shows occurrence code 24 or 25 (insurance denied) and the date of denial in FLs 32-35 (occurrence codes). In addition, it provides the reason for the denial in Remarks (FL 84). Medicare primary benefits cannot be paid when a GHP offers only secondary coverage of services covered by Medicare and it does not allege that the employer has fewer than 20 employees (or 100 employees in the case of disabled beneficiaries). The provider enters occurrence code 24 (insurance denied) and the date of denial in FLs 32-35 (occurrence codes). In addition, it enters the annotation "Plan offers secondary coverage of services covered by Medicare."