Quarterly Frequently Asked Questions (FAQs): June 2019

Question: My patient’s claim was initially billed to a group health plan (GHP) as primary and Medicare as secondary. The primary insurer paid but then came back and recouped their payment because the patient updated their coordination of benefits (COB) record to Medicare primary. How do we get Medicare to reprocess the claim as primary now?

Answer:

If the claim is within the one year timely filing period and Medicare Part B has not made a secondary payment for the date of service. Resubmit the claim and if the coordination of benefits (COB) information has been updated showing Medicare as primary, the claim will process accordingly.
If the claim is within the one year timely filing period and Medicare Part B has already made a secondary payment for the date of service. Appeal the initial claim payment within 120 days from the date of the initial determination. Submitting a new claim would not be appropriate since it would deny as a duplicate.
If the primary recoups past the timely filing limit. Appeal the Medicare claim once you file the claim to Medicare and receive the timely filing denial. Include information explaining why the claim was not filed timely. It will be reviewed based on the individual circumstances and documentation submitted.

Question: What is the filing limit for Medicare Secondary Payer (MSP) claims?

Answer: The timely filing requirement for primary or secondary claims is one calendar year (12 months) from the date of service. Providers should follow-up with primary insurers if there is a delay in processing that may result in going past the Medicare timely filing limit.

Question: When we try to contact the Benefits Coordination & Recovery Center (BCRC) to update the beneficiary’s Medicare Secondary Payer (MSP) record, they advise that the patient must contact them and that they cannot update the record based on the provider calling in.

Answer: The Benefits Coordination & Recovery Center (BCRC) has CMS directives regarding which pieces of MSP information can be updated by a provider. Most items require the patient to update the information. You do have the option of doing a three-way call with the patient to help assist getting the patient to update their information. In some cases on a three-way call with the patient and BCRC the patient can give the call center representative permission to speak with you and update the information.

Question: How do we get our claim paid if the diagnosis we are billing is similar to a diagnosis listed for a no fault or Workers’ Compensation (WC) claim on the beneficiary’s Common Working File (CWF) record but the services are not related to those claims?

Answer: If you have submitted a claim and received a denial indicating that the claim is related to a no-fault or Workers’ Compensation (WC) case, you can submit an appeal explaining that the services are non-related.

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