When Primary Benefits and Conditional Primary Medicare

40.6.2 - When Primary Benefits and Conditional Primary Medicare Benefits Are Not Payable (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) Neither primary nor conditional primary Medicare payments may be made where a GHP denies payment for particular services because: • The services are not covered by the plan, and there is reason to believe the plan does cover the services; • The plan offers only secondary coverage of services covered by Medicare. Conditional primary benefits may not be paid in this situation even if the GHP has only collected premiums for secondary rather than primary coverage. Where a GHP has denied the claim because the plan provides only secondary coverage, the Medicare claims processing A/B MACs and DME MACs denied the claim for Medicare primary benefits and follows the instructions in §10.7; • The plan limits its payments when the individual is entitled to Medicare; • The services are covered under the GHP for younger employees and spouses but not for employees and spouses age 65 or over; • The provider fails to file a proper claim for any reason other than the physical or mental incapacity of the beneficiary; or, • When the employer plan fails to furnish information that is requested by CMS and that is necessary to determine whether the employer plan is primary to Medicare. In addition to the bullet points stated above, Medicare primary or conditional primary Medicare benefits are not payable for the following reasons: A) For no-fault insurance or workers’ compensation situations, A/B MACs and DME MACs shall deny claims where the following conditions are met: (1) the claim is a no-fault insurance or workers’ compensation claim; (2) there is a GHP record on the MSP auxiliary file; (3) the claim was not sent to the GHP; (4) and the physician, provider, or supplier sent the claim to the no-fault or workers’ compensation entity, but the no-fault or workers’ compensation entity did not pay the claim; (5) there is an open ORM MSP record on CWF; or (6) the CARC explaining the reason for denial was not identified on the claim. A/B MACs and DME MACs shall deny claims where the following conditions are met: (1) the claim is a no-fault insurance or workers’ compensation claim; (2) there is a GHP record on the MSP auxiliary file; (3) the GHP denied the claim because the GHP asserted that the no-fault insurer or workers’ compensation entity should pay first; (4) and the physician, provider, or supplier sent the claim to the no-fault insurer or workers’ compensation entity, but the no-fault or workers’ compensation entity did not pay the claim; (5) there is an open ORM MSP record on CWF; or (6) the CARC explaining the reason for denial was not identified on the claim. For Liability insurance claims (including self-insurance), A/B MACs and DME MACs shall deny claims where the following conditions are met: (1) the claim is a liability claim; (2) there is a GHP record on the MSP auxiliary file; (3) the claim was not sent to the GHP; (4) and the physician, provider, or other supplier sent the claim to the liability insurer (including the self-insurer), but the liability insurer (including the self- insurer) did not pay the claim; 5) there is an open ORM MSP record on CWF; or (6) the CARC explaining the reason for denial was not identified on the claim. A/B MACs and DME MACs shall deny claims where the following conditions are met: (1) the claim is a liability insurance (including self-insurance) claim; (2) there is a GHP record on the MSP auxiliary file; (3) the GHP denied the claim because the GHP asserted that liability insurer (including the self-insurer) should pay first; (4) and the physician, provider, or other supplier sent the claim to the liability insurer (including the self-insurer), but the liability insurer (including self-insurer) did not pay the claim; 5) there is an open ORM MSP record on CWF; or (6) the CARC explaining the reason for denial was not identified on the claim. Note: Individuals are not required to file a claim with a liability insurer or required to cooperate with a provider in filing such a claim. However, beneficiaries are required to cooperate in the filing of no-fault and workers’ compensation claims. If the beneficiary refuses to cooperate in filing of no-fault or workers’ compensation claims, Medicare does not pay. Conditional benefits are not payable if payment cannot be made under no-fault insurance because the provider or the beneficiary failed to file a proper claim. (See Chapter 1, §20, for definition.) Exception: When failure to file a proper claim is due to mental or physical incapacity of the beneficiary, and the provider could not have known that a no-fault claim was involved, this rule does not apply.