A/B MAC (Part A) Processing Procedures for Medicare

40.8 - A/B MAC (Part A) Processing Procedures for Medicare Secondary Claims (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) If a primary payment for Medicare covered services is less than the provider's charges for those services and less than the gross amount payable by Medicare (as defined below) in the absence of a primary payment, and the provider does not accept and is not obligated to accept the primary payment as payment in full, Medicare secondary benefits may be paid. In this situation, and where the employer plan paid an amount that equals or exceeds the amount that Medicare would have paid in the absence of a primary payment, the instructions below describe processing claims from providers on cost reimbursement, and providers on prospective payment. If payment by the primary payer for Medicare covered services (as determined by the formula below) equals or exceeds the provider's full charges for those services or the Medicare gross payment amount (without regard to deductible or coinsurance) or the provider accepts, or is obligated to accept, the primary payment as payment in full for the services, and it receives this amount, no payment is due from Medicare and no inpatient utilization is charged to the beneficiary. The provider submits a bill according to the procedures described in the Pub. 100-04, Medicare Claims Processing Manual, Chapter 3, "Inpatient Hospital Billing," for no- payment bills.