Page 13 - Medicare Benefit Policy Manual

provided the beneficiary submits a copy of the VA’s explanation of benefits which
accompanies the VA payment.

The VA explanation of benefits generally consists of a computer-generated notice,
which looks much like a punch card. It contains the beneficiary’s name and social
security number, the physician’s or supplier’s name, the month of service, and the
amount paid. (The VA plans to add the day of service to the notice.) The VA sends
this notice to the party that receives the payment (i.e., the beneficiary or the
physician/supplier). In some cases, the VA may also send a letter containing more
detailed information. If the A/B MAC (B) cannot determine from the VA notice the
amount the VA paid for particular services, it asks the physician or supplier to help it
match up the VA payment with specific services for which Medicare has been billed.
If the A/B MAC (B) is unable to obtain the help it needs from the physician or
supplier, it make reasonable assumptions about the relationship between the VA
payment and the services which have been billed to Medicare based on the
information available to it.

The Medicare secondary benefit amount, where the VA payment to the beneficiary or
physician is less than the allowable amount, is the lower of the following:

• The Medicare allowable amount minus applicable Medicare deductible
and coinsurance amounts; or

• The Medicare allowable amount minus the VA payment.

EXAMPLE: An individual who is authorized by the VA to receive physician services
for treatment of a nonservice-connected condition is issued a fee basis card. The
individual receives treatment from a physician who charges $135. The physician does
not accept the fee basis card. The individual bills the VA directly. The VA pays the
individual $82 ($96 fee basis rate minus $14 outpatient copayment). The Medicare
allowable amount for the service is $115. The individual’s unmet Part B deductible is
$75. The Medicare secondary benefit is the lower of:

• The Medicare allowable amount minus applicable deductible and
coinsurance amounts:

$115 - $75 = $40 X .80 = $32, or

• The Medicare allowable amount minus the VA payment:

$115 - $82 = $33.

The A/B MAC (B) pays $32, the lower of $32 or $33.

The beneficiary’s Part B deductible is considered met by the VA payment.