CMS Pub. 100-05, ch. 3, § 30.2.2

Compensation (WC)

(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)

Information supplied by the provider is one of the means of alerting the A/B MACs (Part A) to

actual or potential WC coverage. A condition is work-related if it resulted from an accident that

occurred on the job or from an occupational disease. The billing form is completed in accordance

with Pub 100-04, Medicare Claims Processing Manual, Chapter 25, "Completing and Processing

the Form CMS 1450 Data Set" when any of the following apply:

• The provider or the patient states that the condition is work-related;

• The condition, or serious aggravation thereof, resulted from an accident which

occurred in the course of the individual's employment, e.g., the patient fell from a

scaffold while at work;

• The diagnosis is one which is commonly associated with employment, e.g.,

pneumoconiosis (including silicosis, asbestosis, and "black lung" disease in the

case of a coal miner); radiation sickness, anthrax, undulant fever; dermatitis due

to contact with industrial compounds; and lead, arsenic, or mercury poisoning;

• The beneficiary previously received workers’ compensation for the same

condition;

• There is indication that a workers’ compensation claim is pending; or

• There is other indication that the condition arose on the job.

Where there is an indication that workers’ compensation may pay for the services, the provider

bills the WC carrier. If WC pays for all of the services (whether at the provider's customary

charge rate or at a special WC rate) the provider submits a Medicare bill indicating the insurer

paid in full. The beneficiary’s Medicare deductible will be credited, however no payment will be

made.

If the provider's WC claim is denied, the provider determines whether any other MSP provisions

apply and bills accordingly. If no other primary payers are available, the provider submits:

• A bill in accordance with the regular billing procedures indicating occurrence

code 24 (insurance denied) and the date of denial in FL 31-36; an

• A supplementary statement calling attention to the fact that workers’

compensation has denied payment or annotates FL 80, remarks, with the reason.

Providers, Physicians and other suppliers must follow the appropriate billing requirements to bill

Medicare in Liability insurance (including self-insurance), No Fault insurance or Workers’

Compensation situations, and also as identified in Pub. 100-05, Chapter 5.

30.2.2.1 Responsibility of Provider Where Benefits May be Payable Under a Workers’

Compensation Medicare Set-Aside Agreement (WCMSA)

(Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23)

A WCMSA is an agreement between the CMS and the CMS beneficiary about what value

of settlement funds must be spent for care related to all settled WC injuries or illnesses

before Medicare begins primary payment for those settled injuries or illnesses.

Indicators that a WCMSA may exist include:

• The condition was claimed as work-related and received full-and-final settlement that

included funds for future care;

• The beneficiary previously filed a workers’ compensation claim for the

same condition;

• The beneficiary indicates that a WCMSA exists; or

• The HETS 270/271 transaction shows that a “W” MSP WC record exists.

An MSP record is not a reason to deny services, but information as to who is the appropriate

primary payer for that situation. Providers must first verify via the HETS 270/271 transaction

whether a “W” record exists. Where there is an indication showing a “W” MSP WCMSA record exists,

the patient should have a WCMSA that may pay for services, and the provider bills the patient,

directly. If the WCMSA does not pay for all of the services due to total exhaustion the provider may

submit a Medicare bill indicating what the WCMSA paid. Medicare may then pay as a primary or

secondary payer, dependent upon the WCMSA status. The provider should determine whether any

other MSP provisions apply and bill accordingly. If no other primary payers are available, the

provider submits:

• A bill in accordance with the regular billing procedures indicating

occurrence code 24 (insurance denied) and the date of denial in FL 31-36;

and

• A supplementary statement calling attention to the fact that WCMSA denied

payment or annotates FL 80, remarks, with the reason.