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  • Medicare Secondary Payer (MSP) Manual Chapter 7 - Contractor MSP Recovery Rules

    Table of Contents (Rev. 59, 02-22-08)

    Transmittals for Chapter 7 Crosswalk to Old Manuals

    10 - General

    10.1 IRS/SSA/CMS Data Match (Data Match) GHP Identified Cases

    10.2 Other Than Data Match GHP Identified Cases

    10.3 Other Sources of Recovery Actions

    10.3.1 - GHP Acknowledges Specific Debt (42 CFR 411.25)

    10.3.2 Recovery from the Provider, Physician or Other Supplier

    10.3.3 Recovery from the Beneficiary Who Received Payment from Both Medicare and a GHP

    10.3.4 - Recovery When a State Medicaid Agency Has Also Requested a Refund from the GHP

    10.3.5. - Identification of GHP Mistaken Primary Payments via the Recovery Management System (ReMAS)

    10.3.5.1 Progression of ReMAS GHP Lead Identification

    10.3.5.2 Progression of ReMAS GHP History Search

    10.4 Contractor Recovery Case Files (Audit Trails)

    10.5 - GHP Letters (Used for ReMAS-HIGLAS When the Only Debtor Interfaced to HIGLAS is the Employer)

    10.5.1 - Employer GHP Letter (Used for ReMAS/HIGLAS Users When the Only Debtor Interfaced to HIGLAS is the Employer)

    10.5.1.1 - Important Information for Employers

    10.5.2 - Insurer GHP Letter (Used for ReMAS/HIGLAS Users When the Only Debtor Interfaced to HIGLAS is the Employer)

    10.5.3 - Provider, Physician or other Supplier GHP Demand Letter (DPP Scenario)

    10.5.4 - Beneficiary GHP Demand Letter (DPP Scenario)

    10.6 Accountability Worksheet (Not Applicable to ReMAS/HIGLAS Users)

    http://www.cms.hhs.gov/manuals/105_msp/msp105c07crosswalk.pdf

  • 10.7 - MSP Summary Data Sheet (Not Applicable to ReMAS/HIGLAS Users)

    10.7.1 - Field Descriptions on the MSP Summary Data Sheet

    10.8 Payment Record Summary (Used with ReMAS/HIGLAS Users but in a Modified Format)

    10.8.1 - Field Descriptions on the MSP Summary Data Sheet

    10.9 Courtesy Copy of All MSP Employer GHP-Based Recovery Demand Packages to the Employers Insurer/Third Party Administrator (TPA)

    10.9.1 Insurer/TPA Courtesy Copy Letter

    10.10 ReMAS Error Reports 10.10.1 Insurer/TPA Letter

    10.11 ReMAS/HIGLAS GHP General Information

    10.11.1 - ReMAS/HIGLAS GHP Demand Process

    10.11.2 - ReMAS/HIGLAS GHP Demand Letter

    10.11.2.1 - How to Resolve This Demand

    20 - Medicare Right of Recovery

    20.1 - Conflicting Claims by Medicare and Medicaid

    20.2 - State Law or Contract Provides That No-Fault Insurance Is Secondary to Other Insurance

    20.3 - Coordination of Benefits Arrangements Between Private Plans

    20.4 - Procedures for Actions With Legal Implications in MSP Situations

    20.4.1 - Handling Freedom of Information (FOIA) and Subpoena Duces Tecum Received in the MSP Units

    20.4.2 - Referral of Cases to Regional Office for Possible Government Intervention and/or Legal Action

    20.4.3 - Other Referrals to CMS

    20.4.3.1 - Refer Nonresponsive Workers Compensation Cases to the CMS

    20.5 - Mistaken GHP Primary Payments

    30 Mistaken Primary Payment Activities and Record Layouts

    30.1 - Contractor Actions Upon Receipt of the Data Match Cycle Tape or Other Notice of Non-Data Match GHP Mistaken Payments (For contractor NOT on ReMAS/HIGLAS for GHP recovery) and Actions to take for those Contractors Using ReMAS/HIGLAS GHP Functions)

    30.1.1 - COBC Responsibility to Obtain Missing MSP Information

  • 30.1.1.2 - When Time Limitation for Non-Data Match Recovery Begins

    30.1.1.2.1 - Actual Notice

    30.1.2 - Contractor History Search

    30.1.2.1 - Aggregate Claims for Recovery

    30.1.3 - Documentation of Debt

    30.1.4 - Documentation of Debt

    30.2 IRS/SSA/CMS Mistaken Payment Recovery Tracking System (MPaRTS)

    30.2.4 - Hospice Mistaken Payment Report Record Layout

    30.2.5 - Part B Payment Record Mistaken Payment Report Record Layout

    30.3 - Communications Received in Response to Recovery Actions

    30.4 - Communications Received in Response to Recovery Actions

    30.5 - Recovery From the Provider

    30.6 - Recovery From the Beneficiary

    40 - Overpayment Due to Workers Compensation Coverage

    40.1 - Action Subsequent to Conditional Payment

    40.1.1 - Time Limit for Filing Workers Compensation (WC) Claim Has Expired

    40.2 - Recover Medicare Payments When Workers Compensation is Responsible

    40.2.1 - COBC Determines Lead Contractor for Recovery in WC Cases

    40.2.2 - Duplicate Payment Received by Provider

    40.2.3 - Medicare Paid for Services Which Should Have Been Paid for by Workers Compensation

    40.3 - Settlement Issues

    40.3.1 - Medicare Made Party to WC Hearing

    40.3.2 - Party Requests That Medicare Accept Less Than Its Claim

    40.3.3 - Authorities for Agreeing to Compromise or Waive Medicares Claim

    40.3.4 - Effect of Lump Sum Compromise Settlement

    40.3.4.1 - Apportionment of a Lump Sum Compromise Settlement of Contested WC Claim

    40.3.5 - Workers Compensation: Commutation of Future Benefits

    40.3.5.1 - Questions and Answers Concerning WC Commutation of Future Benefits

    50 - Recoveries From Liability Insurance Including No-Fault Insurance, Uninsured, or Under-Insured Motorist Insurance

  • 50.1 - General Operational Instructions

    50.2 - Providers and Beneficiarys Responsibility With Respect to No-Fault Insurance

    50.2.1 - Claimants Right to Take Legal Action Against a GHP

    50.2.2 - Conditional Primary Medicare Benefits

    50.2.3 - Services Covered Under No-Fault Insurance and Liability Claim Also Filed

    50.3 - Action if a Liability Insurance Payment Has Been Made to the Provider or Physician Who Accepted Medicare Assignment

    50.3.1 - Insurance Pays Service Benefits

    50.3.2 - No-Fault Insurance Does Not Pay All Charges Because of Deductible or Coinsurance Provision in Policy

    50.3.3 - Other Situations

    50.4 - Pre-Settlement Issues

    50.4.1 - Existence of Overpayment

    50.4.2 - Pre-Settlement Negotiations, Compromises, and Discussions With Beneficiaries/Attorneys

    50.4.3 - Pre-Settlement Communications

    50.4.4 - Designations in Settlements

    50.4.5 - Allegation of Preexisting Conditions

    50.5 - Contractor Action if a Liability Claim Is Pending and Medicare Benefits Were Paid

    50.5.1 - Contractor Coordination Responsibilities

    50.5.1.1 - Lead Contractor Responsibilities

    50.5.1.2 - Non-Lead Contractor Responsibilities

    50.5.2 - Contractor Settlement Communications/Correspondence

    50.5.2.1 - Issuance of Recovery Letter

    Exhibit 2 - Standard Recovery/Initial Determination Letter to Beneficiary

    50.5.2.2 - Exhibit 1 - Calculating Medicares Share of Procurement Costs

    50.5.2.3 - Collecting Interest on the Liability Claim

    50.5.2.4 - Release Agreement Form

    50.5.2.4.1 - Release Agreement Form (Exhibit 7)

    50.5.3 - Recovery From Liability Insurers

    50.5.4 - Recovery From the Beneficiary

  • 50.5.4.1 - Recovery From Estate of Deceased Beneficiary

    50.5.4.1.1 - Wrongful Death Statutes

    50.5.4.2 - Beneficiary Fails to Respond to Requests for Payment

    50.5.4.3 - Beneficiary Refunds to Medicare

    50.5.4.4 - Beneficiary Requests Reduction or Waiver of Medicares Claim

    50.5.4.4.1 - Beneficiary Must Submit Waiver Request

    50.5.4.4.2 - Standard Letter Acknowledging Waiver Request (Exhibit 11)

    Exhibit 11 - Standard Letter Acknowledging Waiver Request

    50.5.4.4. 3 - Timely Processing of Waiver Determinations

    50.6 - Contractor Criteria for Waiver Determinations

    50.6.1 - Waiver Determination Under 1870(c): Step 1 Collect All Pertinent Data

    50.6.2 - Waiver Determination Under 1870(c): Step 2 - Apply Waiver Criteria

    50.6.3 - Factors to Consider in Determining if a Full or Partial Waiver is Warranted: Step 3

    50.6.3.1 - Allowing Out-of-Pocket Expenses in Waiver Determinations

    50.6.3.2 - Other factual data in Determining if a Full or Partial Waiver is Warranted

    50.6.4 - Determining Beneficiary Fault

    50.6.5 - When Recovery Would Defeat the Purpose of Title II or Title XVIII

    50.6.5.1 - Examples of Financial Hardship

    50.6.5.2 - Recovery Would Be Against Equity and Good Conscience

    50.6.5.3 - When the Beneficiary Fails to Meet Either Waiver Criterion Under 1870(c)

    50.6.5.4 - Waiver Indicators

    50.6.5.4.1 - Letter for Granting a Full Waiver (Exhibit 4)

    Exhibit 4 - Letter for Granting a Full Waiver

    50.6.5.4.2 - Letter for Granting A Partial Waiver (Exhibit 5)

    Exhibit 5 - Letter for Granting a Partial Waiver

    50.6.5.4.3 - Letter if Waiver Criteria Are Not Met (Exhibit 6)

    Exhibit 6 - Letter if Waiver Criteria Are Not Met

    50.7 - Waiver and/or Compromise Exercised Only by CMS

    50.7.1 - Waiver Under 1862(b) of the Social Security Act

  • 50.7.2 - Compromise of Claim, or Suspension or Termination of Collection, Under the Federal Claims Collection Act (31 U.S.C. 3711)

    50.7.3 - Documentation Necessary for Liability Cases Forwarded to CMS Where Waiver or Compromise is Requested

    50.8 - Appeals Procedures for MSP Liability Overpayments

    50.8.1 - Initial Determinations

    50.8.2 - Notification of the Right to Appeal

    50.8.3 - Part A and Part B Appeals of MSP Liability Overpayments

    50.8.3.1 - Standard Reconsideration of Overpayment Determination/ Computation (Exhibit 13)

    Exhibit 13 - Standard Reconsideration of Overpayment Determination/Computation

    50.8.3.2 - Standard Reconsideration of Waiver Determination (Exhibit 14)

    Exhibit 14 - Standard Reconside

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