CMS Pub. 100-05, ch. 5, § 40.7

Medicare Secondary Claims

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

A. Validity Edits

A/B MACs (Part B) and DME MACs are responsible for validating the data submitted

on Medicare claims including MSP data.

A/B MACs (Part B) and DME MACs use the date of birth in CWF records to determine the

month and year of birth. When the patient is the spouse of the worker, the A/B MAC (Part

B) and the DME MAC obtains the date of birth of both the worker and the spouse. The A/B

MAC (Part B) and DME MAC presumes that the day of birth is not the first of the month

unless information on the claim form indicates that it is. A person is considered 65 or 70 for

the month if he "attains" 65 or 70 any time during the month. For Medicare entitlement

purposes, a person attains a particular age on the day before his or her birthday. Therefore, if

a person's 65th birthday is on the first day of a month, Medicare is secondary payer

beginning with the first day of the preceding month.

B. Verify Part A entitlement

For purposes of reviewing working aged claims, the A/B MAC (Part B) and DME MAC

presumes that Part A entitlement exists for all Medicare beneficiaries between 65 and 69

except those who are uninsured.

C. Determine if Group Health Plan Coverage Exists

Chapter 1 contains a complete discussion of "employer" and "employer group health

plan." The MSP Contractor is now responsible for developing whether Group Health

Plan (GHP) coverage exists. If the A/B MAC (Part B) and DME MAC becomes aware

that GHP is involved in a claim, for example, through receipt of a claim for secondary

benefits with an EOB, or an electronic claim and this is not reflected in the CWF

response for the claim, the A/B MAC then updates the CWF auxiliary file with an "I"

indicator to add the new MSP occurrence (see §10.1, subsection 2). DME MACs submit

an ECRS inquiry, DME MACs do not submit “I” records. For situations when a

voluntary refund is received with GHP coverage identified and CWF record does not

exist an ECRS Inquiry is sent to the MSP Contractor.