GHP Recovery Instructions to A/B MACs and DME MACs

20.5 – GHP Recovery Instructions to A/B MACs and DME MACs (Rev. 12438; Issued: 01-04-24; Effective: 02-06-24; Implementation: 02-06-24) When a provider, physician, or other supplier receives primary payment from a GHP where Medicare has also paid primary, the provider, physician, or other supplier submits an adjustment bill showing the primary payment amount. The A/B MACs and DME MACs instructs the provider, physician, or other supplier to return to the beneficiary the amounts of the Medicare deductible and coinsurance already paid. The provider, physician, or other supplier may retain any excess GHP payment over the gross amount payable by Medicare. Prior to the activation of the automated Duplicate Primary Payment process, as described in §20.5.1, if duplicate payment was made to the provider, physician, or other supplier (i.e., the provider, physician, or other supplier received or expects to receive both primary GHP payments and primary Medicare benefits), the A/B MACs and DME MACs collected the Medicare overpayment from the provider physician, or other supplier. The A/B MACs and DME MACs then reprocessed or adjusted the claim to determine Medicare’s corrected payment amount. If Medicare paid the provider, physician, or other supplier but the GHP paid the beneficiary, the provider, physician, or other supplier was determined to be liable. (See Pub. 100-06, Medicare Financial Management Manual, Chapter 3, § 90). The A/B MACs and DME MACs recouped the payment from the provider, physician, or other supplier in accordance with the Medicare Financial Management Manual, Chapter 3, § 90. The recoupment was completed by the provider, physician, or other supplier. As part of this process, the A/B MACs and DME MACs obtained a copy of the plan’s Explanation of Benefits (EOB) from the GHP or employer/ other plan sponsor in order to determine the excess Medicare payment. If an adjustment bill was not received from the provider, physician, or other supplier within 120 calendar days of notifying the provider, physician, or other supplier to file a claim with the GHP, or the provider, physician, or other supplier refunded the incorrect payment to the A/B MACs and DME MACs using the quarterly Credit Balance Report, the A/B MACs and DME MACs followed up to determine the status of the claim. If a credit balance report has not been utilized, the account receivable should be initiated to the provider. If the GHP has denied the claim for an acceptable reason, the recovery action may be canceled. If the GHP has denied the claim for another reason, or has not responded to the provider, physician, or other supplier’s claim, the MSP Contractor advised the provider, physician, or other supplier that Medicare will attempt to recover from the employer/ other plan sponsor. Additionally, the MSP Contractor advised the provider, physician, or other supplier to notify it immediately upon receipt of payment from the GHP.