Page 15 - Medicare Benefit Policy Manual

When the A/B MAC (B) receives a Y trailer code (code 3) or a code 36, (type code
3), automatic notice from the Health Insurance Master File (which is sent in instances
where a Medicare beneficiary also has a VA fee basis card), it follows the instructions
in the Medicare Secondary Payer (MSP) Manual, Chapter 5, “Contractor Prepayment
Processing Requirements,” §20.3.1. It contacts the physician or supplier to ascertain
whether a claim has been, or will be submitted to the VA based on an authorization of
the VA or based on the fee basis card. If the physician responds that no claim has
been or will be submitted to the VA, the A/B MAC (B) pays the Medicare claim in
the usual manner. If the physician or supplier indicates that a claim has been or will
be submitted to the VA, the A/B MAC (B) denies the Medicare claim. If the
physician fails to respond to the A/B MAC (B)’s inquiry within 30 days, the A/B
MAC (B) denies the claim if the physician has accepted assignment on the grounds
that the physician refuses to furnish information necessary to determine the proper
Medicare payment. (The assignment agreement prohibits the physician from
charging the beneficiary in these cases because the basis for denial is failure to
furnish information, not noncoverage of services.) In unassigned cases, if the
physician fails to respond to the A/B MAC (B)’s inquiry within 30 days, the A/B
MAC (B) pays the Medicare claim in the usual manner. In accordance with a CMS-
VA agreement, no contacts are to be made with the beneficiary, unless the beneficiary
has submitted a claim for secondary Medicare benefits. Ordinarily, the A/B MAC
(B) does not contact the VA for information concerning actual or potential VA
payments; but if a VA facility offers to share such information with it, e.g.,
information about payments to beneficiaries or physicians or about VA authorized
services to beneficiaries, the A/B MAC (B) may work out arrangements with the
facility to receive such information on a periodic basis or on request.

(b) Claim Is for Secondary Medicare Benefits

If the information on the claim indicates that the VA has already paid benefits for the
services, but has not paid all of the charges, the Medicare A/B MAC (B) pays
Medicare secondary benefits in accordance with subsection 4(a) provided the VA
claim was filed by the beneficiary. If the beneficiary submits the VA’s computer
generated notice, the A/B MAC (B) assumes that the beneficiary filed the VA claim
and pays secondary benefits. If it is unclear whether the physician or beneficiary
submitted the VA notification, the A/B MAC (B) assumes that, in unassigned cases,
the beneficiary filed the VA claim and the A/B MAC (B) pays secondary benefits. In
assigned cases, the A/B MAC (B) asks the physician whether the physician or the
beneficiary filed the VA claim. Also, when it is clear that the physician submitted the
computer-generated notice, the A/B MAC (B) asks the physician (on both assigned
and unassigned claims) whether the physician or the beneficiary filed the claim with
the VA (since in either case the VA sends the notice to the physician who receives the
VA payment).

If the physician does not respond within 30 days, the A/B MAC (B) denies benefits,
in assigned cases, because of the physician’s refusal to furnish information necessary