The Recovery of Medicare Duplicate Payment Claims When the Department of

20.5.2 – The Recovery of Medicare Duplicate Payment Claims When the Department of Veteran Affairs (VA) and Medicare Make Payment on the Same Services (Rev. 13156; Issued: 04-16-25; Effective: 01-01-25; Implementation: 01-06-25) The Centers for Medicare & Medicaid Services (CMS) entered into a computer matching agreement (CMA) with the VA which allows CMS to recover duplicate payments made to providers from both Medicare and the VA. For those claims that CMS has the right to recover from providers that billed Medicare and the VA for the same services, the A/B MACs and DME MACs: • Follow the automated Medicare Secondary Payer (MSP) Health Utilization Duplicate Primary Payment (HUDP) Duplicate Primary Payer (DPP) process, as sited in 20.5.1 above, and • Recover claims payments including a modified HUDP DPP claim record layout that will include the VA Duplicate Payment (VADP) claims transaction using the claim indicator value of “V” for identified duplicate VA claims. Note that the VADP claim recoveries are not MSP recoveries as no VA MSP record exists on CWF. This claim recovery activity is referred to as the VADP process. The duplicate claim data will be sent from the VA to the CMS Integrated Data Repository (IDR). The IDR provides the VADP recovery claim data file to the MSP System Contractor. The MSP System Contractor submits the VADP information to CWF included with the HUDP DPP file. The VADP file identifies all full denial/recovery claims for MACs to recover from providers, physicians and other suppliers for which Medicare has the right to recover. This file identifies descriptions/list of valid values to reflect required data for VADP claims that contain the necessary VA information for the shared system to identify Medicare claims and for the A/B MACs and DME MACs perform needed adjustments/recoveries. Note, that the MSP Systen Contractor will not include claims of service prior to June 6, 2019 as the VADP will only include claims for service beginning June 6, 2019. Note, If the A/B MACs and DME MACs recovered/adjusted VA claims for claims of service prior to June 6, 2019, due to current routine recovery processes, the A/B MACs and DME MACs are allowed to continue to accept and adjust these claims, as necessary, under current recovery processes. CWF accepts the VA transaction from the MSP system contractor that contains the Medicare Duplicate Payment data. This file contains claims information that is sent to the correct A/B MAC and DME MAC for recovery purposes. These records will be sent daily and may not always contain VADP claim. After CWF has transmitted VADP records to the shared system identifying the correct A/B MAC or DME MAC, CWF also accepts all VADP adjustments generated by the shared system, or individually, by the A/B MAC or DME MAC which is part of normal claims processing. CWF applies all customary CWF editing to the VADP recovery/adjustment claims, as necessary. Once the shared system sends the daily report to the respective A/B MAC or DME MAC, the A/B MAC or DME MAC shall work these VADP recovery transactions, request recovery from the appropriate physician, provider and other suppliers and capture VADP savings. For those claims that do not match the Part A and Part B shared systems reports off-line (purged from history) claims and could not be retrieved in the system send this claim information to the appropriate A/B MAC or DME MAC daily for review and manual resolution. The shared systems include detail regarding what required data elements were missing or what specific issue was encountered that prevented successful adjustment claim creation when creating the daily reports. A/B MACs and DME MACs will resolve these claims issues manually. Those claims that are resolved must also be reported as VA Savings, manually too as necessary. All A/B MACs (Part B) and DME MACs shall always set the 935 indicators to “Y.” For VADP adjustments, A/B MACs and DME MACs shall process these claims as 935 adjustments, as set by the assigned reason/discovery code. FISS automatically sets up the VADP adjustment claims with the 935 indicator properly set. The exception to this requirement is provider-initiated or requested adjustments, which are not subject to the 935 requirements (for more information, see Pub.100-06, chapter 3, section 200.) Note, when there is conflicting information between the data on the VADP record and the claim within the A/B MAC or DME MAC’s claims history and there is no manual resolution to the claim, the A/B MAC or DME MAC will cancel the VADP claim and no VA savings is taken. Follow your current policy and procedures on resolving claims issues like this when recovering Medicare payments from providers. The A/B MACs (Part A) and A/B MACs (Part B), with assistance as necessary from their DRaaS-CACHE Data Center (s), • Stores all VADP claim responses from CWF, as received by the shared system, as part of the VADP process; and • Have the ability to print off all stored VADP reports and related DP information. (Note: All related tasks above shall be available for a minimum of 12 months from the date of creation.) The A/B MACs and DME MACs shall use the following messages, as applicable, on their remittance advice and Medicare Summary Notice when VADP claims are recovered/adjusted: Claim Adjustment Reason Code (CARC) 16 - Claim/service lacks information or has submission/billing error(s). Group Code (GC): CO - Contractual Obligation Remittance Advice Remark Code (RARC) – M79 - Missing/incomplete/invalid charge. RARC: MA67 Alert: Correction to a prior claim. Medicare Summary Notice (MSN) - 31.9 - This claim was adjusted because there was an error in billing. MSN - 16.34 - You should not be billed for this service. You are only responsible for any deductible and coinsurance amounts listed in the "Maximum You May Be Billed" column. VA Savings The A/B MACs and DME MACs and shared systems shall ensure that the VADP Medicare recovery/adjustments be included on the MSP savings report under Special Project Savings 9000 – Central Office Savings - under the VA/Other Federal Programs column in the Contractor Reporting of Operational and Workload Data (CROWD) report. When Value Code 42 is present on a claim, the FISS system and Part A MACs allow for the capture of VA recovery savings for VADP adjustments under Special Project Savings 9000 – Central Office Savings under the VA/Other Federal Programs column in the CROWD report.