CMS Pub. 100-16, ch. mc86c18b, § 140.6

Medicare may not pay for services that are payable under Workers' Compensation (WC)

laws. Where the Medicare HCPP coordinates its own health organization with WC

coverage, it will use the procedures developed by its own organization to identify and

recover costs for services furnished to Medicare members. When the Medicare HCPP

does not coordinate benefits for its own organization, it must establish reasonable

screening procedures to identify potential WC liability situations. If it is determined that

Medicare has paid for items or services which can be or could have been paid for under

WC, the Medicare payment constitutes an overpayment.

All WC acts require that the employer furnish the employee with necessary medical and

hospital services, medicines, transportation, apparatus, nursing care, and other necessary

restorative items and services. For specific information regarding the WC plan of a

particular governmental entity, contact the appropriate agency of the governmental entity.

If payment for services cannot be made by WC because they were furnished by a source

not authorized by WC, the services can be paid for by Medicare.

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The beneficiary is responsible for taking whatever action is necessary to obtain payment

under WC where payment under that system can reasonably be expected (e.g., timely

filing of a claim, furnishing all necessary information). If failure to take proper and

timely action results in a loss of WC benefits, Medicare benefits are not payable to the

extent that payment could reasonably have been expected under WC.

NOTE: When failure to file a proper claim is due to mental or physical incapacity of the

beneficiary, and the provider could not have known that WC was involved, this rule does

not apply.