Other Situations

40.8 – Other Situations (Rev. 12438; Issued: 01-04-24; Effective: 02-06-24; Implementation: 02-06-24) In other cases, no-fault insurance may not pay the provider, physician, or other supplier’s charges because the beneficiary’s total medical expenses exceed the dollar limit of the coverage, or because of some other coverage limit, deductible, or coinsurance applicable to all policyholders. (See § 40.7 of this Chapter). A provider, physician, other supplier of services, or any other facility, may not charge a beneficiary or any other party for Medicare covered services, if the provider, physician, other supplier, or facility has been paid by a no-fault insurer an amount that equals or exceeds the gross amount payable by Medicare. This prohibition is based on the terms of their Medicare participation agreements, under which a provider, physician, or other supplier may bill a Medicare beneficiary only for deductible and coinsurance amounts and for non-covered services. If an MSP Contractor has reason to question the correctness of the amount shown on the Medicare claim as having been paid by no-fault insurance, it confirms the amount with the insurer or beneficiary. A copy of a no-fault insurer’s explanation of benefits is the best evidence.