Amount of GHP Primary Payments

20.1 – Amount of GHP Primary Payments (Rev. 12438; Issued: 01-04-24; Effective: 02-06-24; Implementation: 02-06-24) The GHP (as defined in 42 C.F.R. § 411.101) or other entity representing the GHP sponsor, might request that Medicare pay the GHP, or other entity representing the GHP, the amount that Medicare would have paid if a proper Medicare claim had been filed (or some other amount). Upon presentation of such a claim (even if it is for Medicare covered services which satisfy all of Medicare’s claim filing requirements), the MSP Contractor shall advise the GHP, or other entity representing the GHP, that Medicare law does not authorize payment to an entity other than the beneficiary, provider, physician, or other supplier. Pursuant to 42 CFR §§ 424.70-80, Medicare does not recognize so called “assignments of right to payment” by providers, physicians, other suppliers, and individuals to GHPs. The GHP, employer/ other plan sponsor, or other entity representing the GHP or the employer/ other plan sponsor, may request the MSP Contractor’s assistance in recouping its alleged mistaken primary payment, and in having the provider, physician, or other supplier bill Medicare. The MSP Contractor shall advise the GHP, or other entity representing the GHP, that Medicare may not provide the requested assistance. The MSP Contractor shall further explain that Medicare does not waive its timely filing requirement for initial claims from providers, physicians, or other suppliers and beneficiaries when a GHP recoups its mistaken primary payment. This is because there has been no Governmental error. In addition, Medicare does not re-open claims previously adjudicated and either denied or paid as a secondary payer beyond one year of the date of initial determination on the original claim. This is because Medicare’s regulations establish that good cause for Medicare to re-open a claim after one year does not exist in this situation.