GHP Denies Payment for Primary Benefits

40.3.1 - GHP Denies Payment for Primary Benefits (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) Where a GHP has denied the claim because the plan provides only secondary coverage, the A/B MAC and the DME MAC denies the claim for Medicare primary benefits. If a provider bills a GHP and the plan refuses to pay primary benefits because it claims that its benefits are secondary to Medicare's, the A/B MAC and the DME MAC does not pay conditional benefits. Instead, it suspends the claim and sends an ECRS request to the MSP Contractor for development. If the A/B MAC and 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. The A/B MAC (Part A) should instruct its provider that, if a GHP has denied its claim for primary benefits, the provider must annotate Item 84 "Remarks" of the Medicare claim form with the reason for the denial and enter occurrence code 24 and the date of denial in Items 32 to 35. The A/B MAC (Part A) annotates its records with the reason for the denial to avoid the need for any future recovery efforts. The A/B MAC (Part B) and DME MAC processing a claim with similar GHP involvement would send the beneficiary a denial letter including similar information and state that if the GHP does not pay the full charge, then the beneficiary must submit a claim for secondary benefits including a copy of the GHP's explanation of benefits. If the physician, or supplier accepted assignment, the A/B MAC and DME MAC notifies the physician/supplier and the beneficiary that the beneficiary may not be charged more than the Medicare deductible and coinsurance amounts and charges for noncovered services. (Services that are or could have been paid for by the GHP are not considered "noncovered.") Any denial notice must include appropriate appeals information. The A/B MAC and the DME MAC advises the beneficiary to consult with his or her employer and/or the state insurance commissioner or other official having jurisdiction (such as the U.S. Department of Labor) if he or she believes the GHP should have paid for the services. The A/B MAC and the DME MAC also advises the claimant of the private right of legal action to collect double damages. (See Chapter 2, §40.1.)