Claim Indicates Medicare is the Primary Payer

40.1 - Claim Indicates Medicare is the Primary Payer (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) Where the claimant indicates Medicare is the primary payer, the A/B MACs (Part A), A/B MACs (Part B), and A/B MACs (Part HHH) (collectively referred to as A/B MACs) and the DME MACs assume, in the absence of evidence to the contrary, that the claimant has correctly determined that there is no primary GHP coverage and processes the claim. It pays primary Medicare benefits only if the services were not rendered during a coordination period, or if the GHP denies a claim because the beneficiary is not entitled to benefits under the plan, or benefits under the plan are exhausted for the particular services, or the services are not covered by the GHP, and the beneficiary is not appealing the GHP denial. The A/B MAC and the DME MAC does not pay primary benefits if there is reason to believe that the GHP covers the services. If the A/B MAC and the DME MAC pays primary Medicare benefits and later learns that the beneficiary is appealing the GHP denial, it treats the payment as a conditional primary payment. Any necessary recovery actions will later be initiated by CMS’s Commercial Repayment Center. If the A/B MACs (Part A) believes that a GHP may be the primary payer, it returns the bill to the provider requesting the provider to ascertain whether primary GHP benefits are payable, and if so, to bill for primary benefits. The A/B MAC (Part A) should instruct the provider that if a GHP has denied its claim for primary benefits, the provider must annotate the claim with the reason for the denial and enter occurrence code 24 and the date of denial. No attachment is needed. If the A/B MACs (Part B) believes that a GHP may be the primary payer, the A/B MACs (Part B) will return the bill to the physician or other supplier requesting the provider to ascertain whether primary GHP benefits are payable, and if so, to bill for primary benefits. The A/B MACs (Part B) shall instruct the physician or other supplier on the remittance advice that if a GHP has denied its claim for primary benefits, the provider must annotate the claim with the reason for the denial in the CARC segment. No attachment is needed. When a claim is received from a member of a religious order who has taken a vow of poverty, whose order filed an election under §3121(r) of the IRC, and who does not have group health coverage from employment outside the order, the A/B MAC processes the claim as a primary Medicare claim. A GHP's decision to pay or deny a claim because it determines that the services are or are not medically necessary is not binding on Medicare. The A/B MACs and DME MACs evaluate claims under existing guidelines to assure that Medicare covers the services, regardless of the GHP decision.