Identify Claims with Possible WC Coverage

20.2 - Identify Claims with Possible WC Coverage (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) The A/B MACs and DME MACs must identify claims with possible WC coverage. If the provider submitting the claim provides information that clearly indicates the services will not be covered by WC, the A/B MACs or DME MAC pays the claim. Such indications may be: • A denial letter from the WC carrier; • A supplemental statement is included in “remarks” on the claim form; • Form CMS-1450 claims contain an occurrence code 24 (insurance denied) and the date of denial is reported in FLs 28-32; • For A/B MACs (Part B), completion of block 10 on the Form CMS-1500 indicates another insurer may be involved; • The beneficiary previously received WC for the same condition; • The Common Working File’s MSP auxiliary record contains a “Y” validity indicator and an MSP code (“E” or “H”) that indicates the beneficiary is entitled to Black Lung benefits; 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.) Where it appears that the services may be compensatory by WC, the A/B MAC or DME MACs receiving a claim on which there is an indication of WC coverage, submits an MSP record to CWF using the service date of the claim 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 adjudicates the claim to a final disposition.