CMS Pub. 100-05, ch. 5, § 40.3.1

Where a GHP has denied the claim because the plan provides only secondary coverage, the A/B

MAC and the DME MAC denies the claim for Medicare primary benefits. If a provider bills a GHP

and the plan refuses to pay primary benefits because it claims that its benefits are secondary to

Medicare's, the A/B MAC and the DME MAC does not pay conditional benefits. Instead, it suspends

the claim and sends an ECRS request to the MSP Contractor for development.

If the A/B MAC and DME MAC pays primary Medicare benefits and later learns that the

beneficiary is appealing the GHP denial, it treats the payment as a conditional primary payment.

The A/B MAC (Part A) should instruct its provider that, if a GHP has denied its claim for primary

benefits, the provider must annotate Item 84 "Remarks" of the Medicare claim form with the reason

for the denial and enter occurrence code 24 and the date of denial in Items 32 to 35. The A/B MAC

(Part A) annotates its records with the reason for the denial to avoid the need for any future recovery

efforts.

The A/B MAC (Part B) and DME MAC processing a claim with similar GHP involvement would

send the beneficiary a denial letter including similar information and state that if the GHP does not

pay the full charge, then the beneficiary must submit a claim for secondary benefits including a copy

of the GHP's explanation of benefits. If the physician, or supplier accepted assignment, the A/B MAC

and DME MAC notifies the physician/supplier and the beneficiary that the beneficiary may not be

charged more than the Medicare deductible and coinsurance amounts and charges for noncovered

services. (Services that are or could have been paid for by the GHP are not considered "noncovered.")

Any denial notice must include appropriate appeals information. The A/B MAC and the DME MAC

advises the beneficiary to consult with his or her employer and/or the state insurance commissioner

or other official having jurisdiction (such as the U.S. Department of Labor) if he or she believes the

GHP should have paid for the services. The A/B MAC and the DME MAC also advises the claimant

of the private right of legal action to collect double damages. (See Chapter 2, §40.1.)