A/B MACs (Part B) and DME MACs Processing Procedures for

40.7 - A/B MACs (Part B) and DME MACs Processing Procedures for Medicare Secondary Claims (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) A. Validity Edits A/B MACs (Part B) and DME MACs are responsible for validating the data submitted on Medicare claims including MSP data. A/B MACs (Part B) and DME MACs use the date of birth in CWF records to determine the month and year of birth. When the patient is the spouse of the worker, the A/B MAC (Part B) and the DME MAC obtains the date of birth of both the worker and the spouse. The A/B MAC (Part B) and DME MAC presumes that the day of birth is not the first of the month unless information on the claim form indicates that it is. A person is considered 65 or 70 for the month if he "attains" 65 or 70 any time during the month. For Medicare entitlement purposes, a person attains a particular age on the day before his or her birthday. Therefore, if a person's 65th birthday is on the first day of a month, Medicare is secondary payer beginning with the first day of the preceding month. B. Verify Part A entitlement For purposes of reviewing working aged claims, the A/B MAC (Part B) and DME MAC presumes that Part A entitlement exists for all Medicare beneficiaries between 65 and 69 except those who are uninsured. C. Determine if Group Health Plan Coverage Exists Chapter 1 contains a complete discussion of "employer" and "employer group health plan." The MSP Contractor is now responsible for developing whether Group Health Plan (GHP) coverage exists. If the A/B MAC (Part B) and DME MAC becomes aware that GHP is involved in a claim, for example, through receipt of a claim for secondary benefits with an EOB, or an electronic claim and this is not reflected in the CWF response for the claim, the A/B MAC then updates the CWF auxiliary file with an "I" indicator to add the new MSP occurrence (see §10.1, subsection 2). DME MACs submit an ECRS inquiry, DME MACs do not submit “I” records. For situations when a voluntary refund is received with GHP coverage identified and CWF record does not exist an ECRS Inquiry is sent to the MSP Contractor.