Medicare Residual Payments Due When On-going Responsibility for

20.5 - Medicare Residual Payments Due When On-going Responsibility for Medicals (ORM) Benefits Terminate, or Deplete, During a Beneficiary’s Provider Facility Stay or Upon a Physician, or Supplier, Visit (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) There are situations where ORM benefits may terminate or deplete during a beneficiary’s provider facility stay or upon a physician’s visit and a residual Medicare secondary payment is due. Under these circumstances Medicare may make a residual Medicare secondary payment. The term “residual payment” is defined as: a payment Medicare makes on a claim where available funds have been exhausted from the ORM benefit or responsibility for payment terminates mid-service. The A/B MACs, DME MACs and shared systems may pay this residual secondary payment by sending the primary payer amounts to the MSPPAY module and calculate Medicare’s payment if such services are covered and reimbursable by Medicare. The A/B MAC or DME MAC sends an ECRS Assistance Request to the MSP Contractor to update the ORM record due to the ORM being terminated or when benefits are exhausted. The A/B MACs, DME MACs and shared systems, shall receive, accept, and make a residual payment on electronic No-Fault insurance (CWF MSP Code D, Part A Value Code 14), Workers' Compensation, (CWF MSP Code E, Part A Value Code 15), or Liability insurance (including self- insurance) (CWF MSP Code L, Part A Value Code 47) ORM claims when the CAS segment shows one of the following CARCs and primary payer benefits are terminated, exhausted or the claim contains a partial or zero payment: 27 – Expenses occurred after coverage terminated. 35 – Lifetime benefit maximum has been reached. 119 – Benefit maximum for this time period, or occurrence, has been reached. 149 – Lifetime benefit maximum has been reached for this source/benefit category. The A/B MACs, DME MACs and shared systems shall receive, accept, and make payment on MSP Type 14, 15 and 47 ORM paper (hard copy) claims when the claim includes an attached remittance advice/Explanation of Benefits that: 1) Shows the claim with a zero payment or was not paid in full by the primary payer and a residual payment is due; 2) Is a Medicare covered and reimbursable service; and 3) Contains a reason code for denial or similar verbiage if a reason code is not indicated: • Expenses occurred after the coverage terminated; • Lifetime benefit maximum has been reached; • Benefit maximum for this time period, or occurrence, has been reached; or • Lifetime benefit maximum has been reached for this source/benefit category. NOTE: If a No-Fault insurance (CWF MSP Code D, Part A Value Code 14), Workers' Compensation, (CWF MSP Code E, Part A Value Code 15), or Liability insurance (including self- insurance) (CWF MSP Code L, Part A Value Code 47) electronic, or hard copy claim, is received and the claim contains a partial, or zero, payment from a primary insurer and the claim, or attached primary payer remittance advice/EOB, does not include a reason code for denial or similar verbiage if a reason code is not indicated, the A/B MAC, DME MAC and shared system shall deny the claim based on the CWF utilization 6815, 6816, 6817, and 6818 error code received. In order for the residual payment to occur, CWF performs the following functions: CWF HUIP, HUOP, HUHH, HUHC (HBIP, HBOP, HBHH, and HBHC for BDS) claims allow for a 1-byte field (Residual Payment Indicator) at the claim header level. Valid values for the field = X or space. CWF HUBC and HUDC (HBBC and HBDC for BDS) claims allow for a 1-byte field (Residual Payment Indicator) at the claim header level and at the detail level. Valid values for the field = X or space. NOTE: The shared systems must ensure that the A/B MACs and DME MACs are able to input an “X” at the claim header for those claims, and at the service line level, when applicable, that are sent to CWF for situations when the claim is not paid, or not paid in in full, by the primary payer. CWF shall override the three new ORM utilization error codes (6816, 6817 and 6818) when the A/B MACs and DME MACs determine a residual payment should be made on the claim. The A/B MACs and DME MACs make a residual payment by placing the “X” at the header for the Part A claims, or an ‘X’ at either the header or detail line for Part B Professional and DME MAC claims. The A/B MACs, DME MACs and shared systems must send the primary payer’s MSP amounts, found on the incoming ORM claim, to MSPPAY for Medicare’s Secondary Payment calculation when a residual payment is expected to be made by Medicare. The A/B MAC and DME MAC shall submit an ECRS Request to the MSP contractor to add a termination date to the CWF ORM record when ORM benefits are exhausted or terminated.