Sources That May Identify Other Insurance Coverage

20 - Sources That May Identify Other Insurance Coverage (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) A/B Medicare Administrative Contractors (MACs) (Part A), A/B MACs (Part B), or A/B MACs (Part HHH) (collectively referred to as A/B MACs) and DME MACs use the following guidelines to identify claims for otherwise covered services when there was a possibility that payment had been made or can be made by an insurer primary to Medicare. • Information is received from a provider, physician, supplier, the beneficiary, A/B MAC and DME MAC operations (e.g., medical or utilization review), other non- Medicare counterparts, or any other source indicating Medicare has been billed for services when there is a possibility of payment by an insurer that is primary to Medicare; • The health insurance claim form shows that the services were related to an accident (i.e., the diagnosis is due to trauma) or occupational illness (e.g., black lung disease) or were furnished while the beneficiary was covered by a GHP or an LGHP which is primary to Medicare; • The CWF indicates a validity indicator value of “I” or "Y" showing the presence of MSP coverage; • Information in an A/B MAC or DME MAC record- indicates a primary payer; • There is an indication that the beneficiary previously received benefits or had a claim pending for insurance that is primary to Medicare. The A/B MAC or DME MAC assumes, in the absence of information to the contrary, that this coverage continues; • Medicare has not made payment and the A/B MAC and the DME MAC is asked to endorse a check from another insurer payable to Medicare and some other entity. The A/B MAC or the DME MAC returns the check to the requester and advises that the insurer pay primary benefits to the full extent of the GHP's primary obligation. (The A/B MAC and the DME MAC follows the recovery instructions in Chapter 7, "MSP Recovery," and Chapter 3 of Pub. 100-6, the Medicare Financial Management Manual, if the check relates to services for which Medicare paid primary.) As necessary, it follows up with the provider, physician, supplier, beneficiary, and/or attorney to find out if the beneficiary receives payment from the GHP; • Medicare receives or is informed of a request from an insurance company or attorney for copies of bills or medical records. Providers are instructed to notify the MSP Contractor promptly of such requests and to send a copy of the request. If the request is unavailable, providers are to provide full details of the request, including the name and Medicare beneficiary identifier of the patient, name and address of the insurance company and/or attorney, and date(s) of services for which Medicare has been billed or will be billed; • Where a GHP's primary coverage is established because the individual forwards a copy of the GHP's explanation of benefits and the individual meets the conditions in Chapter 1, §10, the A/B MAC and the DME MAC processes the claim for secondary benefits; • A claim is billed as Medicare primary and it is the first claim received for the beneficiary and there is no indication that previous MSP development has occurred; or • The CWF MSP auxiliary detail screen contains a 1-byte Ongoing Responsibility for Medicals (ORM) indicator, where the value is “Y,” which indicates that a Section 111 Medicare, Medicaid, and S-CHIP Extension Act (MMSEA) Responsible Reporting Entity (RRE) has accepted ongoing responsibility for a particular liability, no-fault, and workers’ compensation incident. NOTE: Further details regarding ORM, the new 1-byte ORM indicator on CWF, and how to handle and process claims based on the value present within the CWF ORM field may be found in Section 2.4 below. Other insurance that may be primary to Medicare is shown on the institutional claim as follows: • A Value Code of 12, 13, 14, 15, 16, 41, 43, 44, or 47; • An Occurrence Code of 01, 02, 03, 04, 05, 24, 25, or 33; • A Condition Code of 02, 05, 06, 77, or D7; • A diagnosis code is shown on the NGHP claim; or • Another insurer is shown as the primary payer on line A of Payer Name. Special Note for Incoming Hard Copy Part B Non-Facility Claims: Other insurance that may be primary to Medicare is shown on the Form CMS-1500 claim form when item 11 is completed. A primary insurer is identified in the "Remarks" portion of the bill. With the installation of the Benefits Coordination & Recovery Center (MSP Contractor), the A/B MACs and DME MACs use ECRS to advise the MSP Contractor of the possibility of another insurer, and awaits MSP Contractor development before processing the claim.