US · guidance
CMS Pub. 100-01, ch. 5, § 10.1.8
Medicare Secondary Payer Involvement of Failure to File
Proper Claims
(Rev. 1, 09-11-02)
This section is a further explanation of §10.1.1.
A provider that has not filed a proper claim and has received a reduced payment because
of this from a payer primary to Medicare agrees:
• To bill Medicare for an amount no greater than would have been payable as
secondary payment if the primary insurer's payment had been based on a proper
claim; and
• To charge the beneficiary only (a) the amount it would have been entitled to
charge if it had filed a proper claim and received payment based on such a claim;
and (b) an amount equal to any third-party payment reduction attributable to
failure to file a proper claim, but only if the provider can show that:
o It failed to file a proper claim solely because the beneficiary, for any
reason other than mental or physical incapacity, failed to give the provider
the necessary information; or
o The beneficiary, who was responsible for filing a proper claim, failed to
do so for any reason other than mental or physical incapacity.
History
(Rev. 1, 09-11-02)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
da854b258a6f3aebc18fdabc563c0aa740dc4adf5dd780b6d4e951e0fa50266f
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