Recovery Where GHP Acknowledges Specific Debt (42 C.F.R. § 411.25)

20.7 – Recovery Where GHP Acknowledges Specific Debt (42 C.F.R. § 411.25) (Rev. 12438; Issued: 01-04-24; Effective: 02-06-24; Implementation: 02-06-24) If a GHP voluntarily and unsolicited by Medicare acknowledges that Medicare made a mistaken primary payment for a specific service and acknowledges that it should have or did make primary payment, the GHP must refund the Medicare primary payment. When an MSP Contractor receives notice from a GHP along with identification of the specific claims for which Medicare mistaken primary payments were made, the MSP Contractor shall: a) Confirm whether a Common Working File record of the MSP situation has been established. If a record has not yet been established, the MSP Contractor shall ensure the MSP occurrence is documented (via the Electronic Correspondence Referral System (ECRS) request, if necessary) no later than 30 calendar days following identification of the new MSP occurrence. b) In the event of identified duplicate primary payments to physicians, providers, or other suppliers, the MSP Contractor should refer those claims to the appropriate A/B MACs and DME MACs for recovery. The A/B MACs and DME MACs shall initiate the recovery process from the provider, physician, or other supplier for the identified duplicate primary payments. The MAC shall follow the instructions listed in Pub. 100-06, Medicare Financial Management Manual, Chapter 3, § 200.1.6. c) In the event of an unsolicited voluntary refund, the MSP Contractor sends notice and a refund check (classified as a voluntary/unsolicited refund) along with identification of the specific claims for which Medicare mistaken primary payments were made. The MSP Contractor shall first: i. Confirm that the payment was intended for GHP debt. Look for any indication that the GHP has advised the MSP Contractor responsible for coordination of benefits of its primary payment responsibility. (e.g., there may be a cc at the bottom of the letter, etc.); ii. If there is no indication that the GHP has advised of its primary payment responsibility, forward the notice information (usually via ECRS). If there is an indication that the GHP has advised CMS of its primary payment responsibility, do not send an ECRS request; iii. Process the refund check as described in Pub. 100-06, Medicare Financial Management Manual, Chapter 5, § 410.4.