GHP Pays Primary Benefits When Not Required

40.4.3 - GHP Pays Primary Benefits When Not Required (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) Cases may come to the A/B MACs and DME MACs attention in which a GHP has mistakenly paid primary benefits for the services of a physician/supplier (e.g., the GHP of an employer of less than 20 employees has paid primary benefits). If the time limits for reopening identified in 100-09, MACs, Beneficiary, and Provider Communications Manual, Chapter 1, permit, and if requested by the provider, physician, other supplier or beneficiary, the A/B MAC and DME MAC reopens the Medicare secondary claim, and pays any additional amount due as primary benefits. The A/B MAC or DME MAC notifies the provider, physician or other supplier of any such Medicare payments. If the A/B MAC (Part B) and DME MAC receives a secondary claim on an assignment basis, it pays the additional amount to the physician/supplier. It instructs the provider, physician or other supplier to refund to the GHP or the beneficiary the amount that the GHP or the beneficiary has paid in excess of the applicable Medicare deductible and coinsurance and charges for noncovered services. If the A/B MAC (Part B) and DME MAC received the secondary claim on an unassigned basis, it pays the additional amount to the beneficiary and advises the beneficiary to make appropriate refund to the GHP. However, Medicare cannot require the beneficiary to make this refund even though the beneficiary may be legally obligated to repay the GHP. When a GHP has mistakenly paid primary benefits for the services of a physician/supplier and no Medicare claim was submitted for those services, the provider, physician or other supplier has the responsibility to submit an assigned or unassigned Medicare claim, as appropriate. (The time limit for filing may be extended if failure to file timely resulted from error or misrepresentation by an employee, A/B MAC or DME MAC, or agent of the DHHS. For this purpose, the Social Security Administration is considered an agent of the DHHS.) In such cases where a GHP has inappropriately paid primary benefits, A/B MACs instructs the provider to bill Medicare as primary payer and to refund to the GHP the amount it paid, except for an amount equivalent to the Medicare deductible and coinsurance amounts, and charges for noncovered services.