CMS Pub. 100-05, ch. 5, § 40.1.1

Coverage (Other Than Federal Black Lung Benefits)

(Rev. 11550; Issued: 08 -12-22; Effective: 10 -13-22; Implementation:10 -13-22)

If the submitted claim or the CWF response indicates WC (excluding Black Lung) is

responsible based upon the diagnosis reported on the claim, the A/B MAC and DME MAC

denies the claim.

The notice to the provider or physician/supplier and beneficiary should:

• State that the services are not covered under Medicare because the law prohibits

payment for services which are reimbursable under a WC law or plan;

• Advise the beneficiary, provider or physician/supplier to submit a claim to the

beneficiary's WC carrier (or employer if the employer is self-insured) and;

• Inform the provider or physician/supplier that if the WC carrier does not pay for all

of the services, the provider or physician/supplier should resubmit the claim to

Medicare for further consideration with a copy of any notification received from the

WC carrier explaining why the services are not reimbursable under WC.

If it is not clear whether WC is responsible, the A/B MAC and DME MAC advises the MSP

Contractor of possible WC involvement and adjudicates the claim based on the results of the MSP

Contractor's development.