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Employer Bulletin

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 steps:

  1. 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.

  2. Once the information is verified, forward the letter from the Medicare Part A Intermediary to the applicable health plan for handling.

  3. 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).


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