State Agencies & Local Health Employers
Vol. 18, No. 13
August 16, 2001
How to Handle A Request for Repayment of Claims by Medicare
A Medicare Intermediary (e.g., Wisconsin Physicians Service, Blue
Cross Blue Shield United of Wisconsin) may contact you in writing
for the repayment of claims for a former or current employee if
Medicare paid as the primary carrier when, in fact, the employer's
group health plan was the primary carrier.
Medicare, administered by the Health Care Financing Administration
(HCFA), may have previously asked you questions regarding the health
insurance coverage and employment status of certain former or current
employees. By cross checking dates of coverage and employment, Medicare
may pursue recovering some of these benefits. The Medicare Secondary
Payer (MSP) provisions of the Social Security Act state that Medicare
may seek to recover a mistaken primary payment from "any entity
which is required or responsible" to pay for medical services
under a primary plan. One of Medicare's regulations, 42 C.F.R.
411.24 (e), provides that "HCFA has a direct right to recover
from any entity responsible for making primary payment. This includes
an employer, an insurance carrier, plan or program . . . . "
Should you receive such a request, please follow these
Verify that the employee(s) was identified to HCFA through
a data match request as having coverage as or through an active
employee. Verify coverage by checking the employee's health
insurance application and employment dates with the previously
filed data match forms sent to HCFA.
Once the information is verified, forward the letter from the
Medicare Part A Intermediary to the applicable health plan for
Attach the enclosed
transmittal memo from ETF to the affected health
plan. The transmittal memo explains the situation to the plan
and advises the plan to handle the repayment request. You must
complete the information at the bottom of the transmittal memo
before sending it to the plan.
ETF has no specific role in coordinating this effort. Please
direct your questions to the appropriate health plan or to the Medicare
Intermediary. For Medicare Part A claims, the intermediary is Blue
Cross Blue Shield (1-800-531-9695). For Medicare Part B claims,
the intermediary is WPS (1-608-221-4711 and ask for the COB department).