Identification of Liability and No-Fault Situations

20.1 - Identification of Liability and No-Fault Situations (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) A/B MACs and DME MACs shall use the indicators listed below to identify claims in which there is a possibility that payment can be made by a liability or no-fault insurer: • The A/B MACs and DME MACs receive information from a physician, a provider, a supplier, a beneficiary, the A/B MACs and DME MACs internal operations (e.g., medical or utilization review) or those of the A/B MACs and DME MACs non-Medicare counterpart, another A/B MAC or DME MAC, or any other source, indicating Medicare has been billed for services when there is a possibility of payment by a liability insurer; • The health insurance claim shows that the services were related to an accident; • The claim shows a complementary insurer as an insurance organization that does not issue health insurance; • The A/B MAC, the DME MAC or the RO is asked to endorse a check from another insurer payable to Medicare and the beneficiary; • The A/B MAC or the DME MAC receives or is informed of a request from an insurance company or from an attorney for copies of bills or medical records; • There is indication that a liability insurer previously paid benefits related to the same injury or illness or that a claim for such benefits is pending. There is no need to investigate this lead, however, if the A/B MAC or the DME MAC records show that the services were furnished after the date of a final liability insurance award or settlement for the same injury or illness, and the award or settlement does not make provisions for payments for future medical services; • The A/B MAC receives an ambulance claim indicating that trauma related services were involved; • The CWF HIMR screen shows that an auxiliary record has been established for a known liability situation; and • A “Y” ORM indicator is present on the MSP auxiliary file for a liability, no-fault or workers’ Compensation record. (See Section 20.4 for more information.) In addition, A/B MACs (Part A) and A/B MACs (Part HHH) use the following indicators on the institutional claim to identify the possibility of payment by a liability insurer. • Another insurer is shown as Payer on line A of Payer Name or a primary payer is identified in "Remarks" on the bill; • Occurrence Codes 01 through 03 or 24 are shown for Occurrence Span Code; • Codes 1 or 2 are shown as the Type of Admission; • Code 14 is the Value Code shown; • Condition Codes 10, 28, 29, D7, and D8 are shown; and • Remarks are shown. For A/B MACs (Part B), completion of block 10 on the Form CMS-1500 indicates another insurer may be involved. The A/B MAC (Part B) receiving a claim on which there is an indication of liability or no-fault coverage submits an MSP record to CWF using the accident date as the effective date of MSP and a validity indicator of "I." This causes CWF to generate an investigation record to the MSP Contractor to ascertain the correct MSP period. The MSP Contractor develops the appropriate MSP dates with the insurer or beneficiary, or other party, as appropriate, and transmits a CWF maintenance transaction to reflect the proper MSP period. Upon receipt of the CWF data, the A/B MAC (Part B) adjudicates the claim per Pub. 100-05, Chapter 3, Section 90.