The following are the situations in which Medicare may be used as and should be billed as a secondary payer to other insurance. The term “other insurance” does not include Medigap, Medicare Supplemental Insurance, CHAMPUS/TRICARE, Medicaid, or Medicare HMO’s.
Employer Group Health Plan Coverage
In each of the below cases, claims should be sent first to the EGHP or LGHP rather than to Medicare. When payment or denial is received from the EGHP or LGHP, Medicare should be billed for consideration of secondary payment.
Working Aged: Patients 65 years or older who have Employer Group Health Plan (EGHP) coverage through their own employment or employment of a spouse. An EGHP is a health insurance or benefit plan that is offered through an employer of 20 or more employees.
Disabled: Patients under age 65 entitled to Medicare on the basis of permanent disability who have health insurance coverage under a Large Group Health Plan (LGHP) either through the coverage of a family member or from their own employment. An LGHP is a health insurance or benefit plan that is offered through an employer who has 100 or more employees or is part of a multi-employer trust or association that has at least one employer of 100 or more employees.
End Stage Renal Disease (ESRD): Patients under age 65 (including dependent children) who are entitled to Medicare solely on the basis of ESRD and who have health insurance coverage under an Employer Group Health Plan (EGHP) as a result of the beneficiary or any family member’s current or former employment. The EGHP may be offered by an employer of any size. Medicare is the secondary payer for ESRD beneficiaries for the first 30 months of their Medicare eligibility. Eligibility is determined by the first month that Medicare could have, upon application, made payments on behalf of the beneficiary.
Automobile/No-Fault or Liability Insurance: When Medicare is the secondary payer to automobile medical/no-fault or liability insurance, you may, but are not required to, bill Medicare for conditional payment. Conditional payment means Medicare will pay the claims as if we had primary responsibility. We will, however, actively pursue recovery of the funds paid by Medicare from the responsible person’s auto or liability insurance. When you have reason to believe that you have provided services to a beneficiary for which payment under liability insurance may be available:
- Bill only the liability insurer during the 120-days after you have provided services unless you have evidence that the liability insurer will not pay within the time period.
- If you have evidence that the liability insurer will not pay within the 120-day timeframe*, you may, but are not required to, bill Medicare for conditional payment. If you bill Medicare within the 120-day time period, supply documentation to support that payment will not be made promptly.
- After the 120-day timeframe has ended, you may, but are not required to, bill Medicare for conditional payment if the liability insurance claim is not resolved. At this point, the 120-day payment documentation is no longer required; however, we still need the liability insurer’s name and address.
*Note: The 120-day timeframe is defined as the earlier of the following:
- The date a claim is filed with an insurer or a lien is filed against a potential liability settlement.
- The date the service was furnished or, in the case of inpatient hospital services, the date of discharge.
Sometimes providers file liens in auto and liability cases and wait for a settlement before submitting a bill to Medicare-this is not considered a conditional payment, as you are not requesting that Medicare pay. However, the 120-day timeframe is still to be followed. If you choose to bill Medicare after the 120-day period you must withdraw claims against the liability insurer or liens placed on the beneficiary’s settlement. The Medicare reimbursement must be accepted as payment in full and you may charge the beneficiary only for applicable deductible, coinsurance, and non-covered services. When the claim you are filing includes a trauma diagnosis and an auto or liability insurance is involved, please include the name, policy number and address of the liability insurer if requesting a secondary or a conditional payment. If liability insurance payment is made, Medicare will not pay secondary unless benefits are exhausted.
Workers Compensation: If the services you provide to a beneficiary are related to an injury that is covered under workers compensation, you must bill the worker’s compensation insurance for payment. If the workers’ compensation benefits are exhausted, you may bill Medicare secondary. If the beneficiary is a Federal employee, the Department of Labor should be billed first. Medicare should be billed only if the claim is denied or contested by the Employer or if you are not required to accept the Workers Compensation payment as payment in full.
Black Lung: Applies to all Medicare beneficiaries and deals with services rendered for a condition attributable to lung disease/conditions caused by mining. The Department of Labor should be billed if the diagnosis is black lung related. If the diagnosis is not black lung related, Medicare should be billed. If the Department of Labor does not pay for the services after being billed, the claim should be filed to Medicare with the Department of Labor’s denial information.
The address for billing to the Department of Labor is:
Federal Black Lung Program
P.O. Box 740
Lanham, Maryland 20706
The following is a complete list of Black Lung diagnosis codes.
|Black Lung Diagnosis Codes|
|A31.0||I28.1||J45.901||R06.00, R06.09, R06.3, R06.83, R06.89|
|C34.00- C34.90||J12.9||J86.0- J86.9||R07.01 & R07.81|
|D02.20||J13 & J18.1||J86.9, J90, J91.8, J94.1, J94.2, J94.8, J94.9, R09.1||R22.2|
|E87.2||J15.0- J15.9||J93.0||R90-R94 & R00-R99|
|E87.3||J18.9||J85.0, J85.1, J85.2||R09.2|
|127.82||J11.1||J98.11 & J98.19|
Veterans and Other Federal Programs
Veterans: Veterans who are also entitled to Medicare can choose which program will be responsible for payment when services are covered by both programs. You do not have to submit claims involving a veteran to the VA for denial before submitting the claim to Medicare. This causes unnecessary claims processing by the VA and inconvenience to the veteran.
Claims for services for which the veteran elects Medicare coverage should be submitted to Medicare in the normal manner. They will be paid without development, assuming the Medicare coverage and eligibility requirements are met.
Claims cannot be submitted to both programs for the same dates and type of treatment. If a veteran elects Medicare coverage, a claim should not be submitted to the VA for the Medicare deductible or coinsurance.
VA advance authorization for care will be via sharing agreement, contract, or written communication. Telephone authorization may be granted in emergency situations. All telephone authorizations are documented by the VA at the time the authorization is granted.
Any VA authorization for inpatient care is terminated when the veteran is determined by the VA to be stable for transfer to a VA facility, or the veteran states that he or she is not willing to be transferred to a VA facility for continued treatment upon stabilization.
Medicare and the VA will be performing periodic computer data matches to assure that instances of duplicate payment are identified. When duplicate payments are found, Medicare will pursue recovery of its payment, and will develop information for potential referral to the Internal Revenue Service or the Office of Inspector General.
Use the following as a guide when submitting claims to Medicare or VA.
Submit claims to the VA as follows:
- When hospital care was authorized by the VA in advance, or within 72 hours of admission.
- When outpatient medical services were authorized by the VA in advance. (Note: A VA Fee Basis ID card is not considered by Medicare to be an authorization and the veteran retains his or her rights to elect VA or Medicare coverage.)
- When care was not authorized by the VA in advance, the veteran is eligible for payment for care as an unauthorized service, and the veteran chooses to submit a claim to the VA for unauthorized services rather than utilizing Medicare benefits.
Submit claims to Medicare as follows:
- When veteran is eligible for Medicare benefits and hospital care was not authorized by the VA in advance, or within 72 hours of admission.
- When veteran is eligible for Medicare benefits, has a VA Fee Basis ID card and elects Medicare coverage over VA.
- When veteran is eligible for Medicare benefits and has no prior authorization from the VA for care-unless the veteran is eligible for payment for care as an unauthorized service, and the veteran chooses to submit a claim to the VA for unauthorized benefits.
- When veteran is eligible for Medicare benefits and the VA has authorized care for only a part of the hospital treatment period.
Other Federal Program: Applies to all Medicare beneficiaries who are eligible for care under other Federal programs such as the Public Health Service. To the extent that services are authorized and eligible under another Federal program, Medicare will not make payment. Claims for services authorized or guaranteed under other Federal Programs should be submitted to that program for payment. No claim should be submitted to Medicare until after the authorizing agency has processed the claim.