Facts Indicate Reasonable Likelihood of Workers' Compensation

40.1.1 - Facts Indicate Reasonable Likelihood of Workers' Compensation Coverage (Other Than Federal Black Lung Benefits) (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) If the submitted claim or the CWF response indicates WC (excluding Black Lung) is responsible based upon the diagnosis reported on the claim, the A/B MAC and DME MAC denies the claim. The notice to the provider or physician/supplier and beneficiary should: • State that the services are not covered under Medicare because the law prohibits payment for services which are reimbursable under a WC law or plan; • Advise the beneficiary, provider or physician/supplier to submit a claim to the beneficiary's WC carrier (or employer if the employer is self-insured) and; • Inform the provider or physician/supplier that if the WC carrier does not pay for all of the services, the provider or physician/supplier should resubmit the claim to Medicare for further consideration with a copy of any notification received from the WC carrier explaining why the services are not reimbursable under WC. If it is not clear whether WC is responsible, the A/B MAC and DME MAC advises the MSP Contractor of possible WC involvement and adjudicates the claim based on the results of the MSP Contractor's development.