GHP Demand Activities

20.4 – GHP Demand Activities (Rev. 12438; Issued: 01-04-24; Effective: 02-06-24; Implementation: 02-06-24) The MSP Contractors shall take the following actions: a) MSP Contractors shall initiate paid claims history searches within the time parameter specified in the MSP Contractor’s Statement of Work (SOW). This information will be used to determine if Medicare mistaken primary payments have been made that meet or exceed recovery tolerances. b) MSP Contractors shall aggregate demand letters with respect to a single employer/ other plan sponsor and insurer/ TPA combination into one package. MSP Contractors shall issue a demand package to the identified debtor (usually the employer or other plan sponsor). The demand package shall include the demand letter as well as a listing of the claims for which Medicare seeks payment, and any other identified enclosures to the letter. c) MSP Contractors shall issue a courtesy copy of the entire employer/ other plan sponsor demand package to the insurer/TPA, with the exception of federal employers, as noted above. In a federal employer situation, the only copy of the demand package shall be the copy issued to the insurer/ TPA. The courtesy copy issued to the insurer/TPA shall include individual claims facsimiles for all claims included in the demand package as well as an explanatory cover letter. Unless directed otherwise, MSP Contractors shall issue all recovery correspondence via first class U.S. Mail. i. In the event the insurer/TPA copy is returned to the MSP Contractor as undeliverable, do not attempt to find a better address. ii. In the event a particular insurer/TPA consistently returns/refuses their courtesy copies of an employer/ other plan sponsor’s demand packages, the MSP Contractor should cease mailing courtesy copies to that insurer/TPA for that employer/ other plan sponsor. d) The employer/ other plan sponsor or other entity acting on the employer/ other plan sponsor’s behalf may respond with a full payment. If the employer/ other plan sponsor or other entity repays Medicare in full (including any applicable interest), the MSP Contractor shall close the recovery case. MSP Contractors shall send an acknowledgment or response to the full payment to the employer/ other plan sponsor with a copy to the insurer/TPA. e) If the employer/ other plan sponsor or other entity provides a full payment for certain services and provides a valid documented defense for all other services, MSP Contractors shall close the case. A valid documented defense consists of evidentiary material demonstrating that the GHP was not obligated to repay Medicare pursuant to the MSP provision (an assertion of a defense without supporting evidence is not a valid documented defense). MSP Contractors shall send an acknowledgment or response for the full payment and acceptance of the valid documented defense offered by notifying the employer/ other plan sponsor if the insurer/TPA had sent in full payment without having an employer/ other plan sponsor authorization to act as its agent. f) If the employer/ other plan sponsor or other entity makes less than a full payment or provides less than a valid documented defense, MSP Contractors shall adjust the debt as appropriate and continue collection activities. MSP Contractors shall send an acknowledgment or response to the partial payment or invalid defense by notifying the employer/ other plan sponsor with a copy to the insurer/TPA. g) To the extent that an employer/ other plan sponsor or the other entity responds with a valid documented defense to any portion of a recovery claim, MSP Contractors shall adjust the debt accordingly. If the valid documented defense is that the GHP made primary payment to a provider, physician, or other supplier, the MSP Contractor shall forward the information about the claim and defenses to the appropriate A/B Medicare Administrative Contractors (MACs) (Part A), A/B MACs (Part B), or A/B MACs (Part HHH) (collectively referred to as A/B MACs) and Durable Medical Equipment MACs (DME MACs) to initiate recovery from the provider, physician, or other supplier. If the valid documented defense is that the GHP made primary payment to the beneficiary, MSP Contractors shall consider this resolution of the claim. MSP Contractors shall adjust the portion of the employer/ other plan sponsor debt, which had been paid directly to the provider, physician, other supplier, or beneficiary. h) If an employer/other plan sponsor requests specific information or asks a specific question about the recovery claim, MSP Contractors shall provide the information or answer the questions.