CMS Pub. 100-16, ch. mc86c17b, § 300

HMOs/CMPs

(Rev. 63, 11-12-04)

Several entities may have jurisdiction over the processing and payment of Part B bills for

an HMO’s/CMP’s members. This could result in duplicate payments to either the

physician, supplier, or to the enrollee. It is incumbent that HCPPs and HMOs/CMPs

establish a system to preclude or detect duplicate payments.

Regardless of the claims option selected, HMOs/CMPs are required to process all non-provider Part B bills, with some exceptions. These exceptions, as noted below, are

processed by the carrier or intermediary:

• Claims for services by an independent physical therapist;

• Claims for outpatient blood transfusions;

• Claims from physicians for dialysis and related services provided through an

approved dialysis facility;

• Claims for home health services received under cost reports beginning on or after

January 1, 2005; and

• Hospice care by Medicare participating hospices, except:

a. Services of the enrollee’s attending physician if the physician is an

employee or contractor of the organization and is not employed by or

under contract to the member’s hospice; and

b. Services not related to the treatment of, or a condition related to, the

terminal condition.

Duplicate payment detection is the responsibility of the HCPP or HMO/CMP, not the

carrier. The HCPP or HMO/CMP should perform several duplicate check functions after

it receives paid claims information. If the HCPP or HMO/CMP has not previously paid

the claim, a copy of the claims information is filed in the beneficiary’s history file. If the

duplicate payment check reveals that the HCPP or HMO/CMP has already paid for the

services:

• Contact the physician/supplier or enrollee to retrieve the overpayment;

• Record any collections as credits on the cost report;

• Notify CMS of unresolved overpayment situations; and

• Do not return payment to the carrier.