Medicare Says Another Insurance Should Pay First

What This Means

Medicare’s response indicates that another insurer may be responsible before Medicare pays. First check which coverage applied to this service on the date you received it. Under Medicare Secondary Payer rules, having other insurance does not always mean that insurance pays first.

X12 reason code 22 identifies possible coverage by another payer; code 20 identifies liability-insurance coverage for an injury or illness. Ask the billing office to explain the full response, including any remark codes. These codes alone do not establish what you owe.

Why This Happens

• Current-employment group coverage may pay first. For people 65 or older with coverage through their own or a spouse’s current employment, the employer-size threshold is generally 20 employees. For people under 65 with Medicare based on disability and coverage through their own or a family member’s current employment, it is generally 100 employees. Multi-employer plans have additional rules; ask the benefits administrator to confirm the payer order.
• The service relates to an accident or work injury. Liability, no-fault insurance, or workers’ compensation may be primary for related care. Medicare may make a conditional payment in some cases when the responsible insurer has not paid promptly. CMS’s conditional-payment rules have limits, including cases with ongoing responsibility for medical expenses or a workers’ compensation Medicare set-aside. A conditional payment may have to be repaid; ask the provider whether this process applies.
• An ESRD coordination period applies. Group health coverage can pay first during the applicable 30-month coordination period for Medicare based on End-Stage Renal Disease. Ask Medicare and your benefits administrator to confirm the dates and how the rule applies to your coverage. Medicare explains ESRD coordination here.
• The insurance record needs correction. Medicare may have outdated information about coverage or employment. Report changes to the BCRC and give the provider the correct insurance information.

Should You Appeal?

For an Original Medicare first-level claim appeal, the contractor must receive your request within 120 calendar days after you receive your Medicare Summary Notice (MSN). Receipt is presumed five days after its date unless evidence shows otherwise. Medicare Advantage uses its plan appeal process; CMS describes the standard first-level filing period as 65 days from the denial notice date. Follow your notice’s instructions while the insurance issue is investigated.

What To Do Next

1. Gather the notices and coverage dates. Find the Medicare response, the other insurer’s explanation of benefits, and any coverage termination notice.
2. Confirm which insurer should pay first for this service. Ask the provider and benefits administrator to check the service date, employment status, and applicable coordination rules.
3. Correct inaccurate insurance records. Call the BCRC at 1-855-798-2627 if Medicare lists incorrect or ended coverage. Keep a record of what you reported.
4. Ask the billing office to use the right claim procedure. Find out whether it needs to bill the primary insurer, correct a returned claim, or pursue a reopening or appeal. Keep track of your own appeal deadline.
5. Check any bill you receive. Ask what remains your responsibility after both payers process the claim. Medicare may not pay all costs the primary insurer leaves unpaid. For help understanding the notices, call 1-800-MEDICARE (1-800-633-4227) or your State Health Insurance Assistance Program (SHIP).

Sources

• CMS: Medicare Secondary Payer.
• CMS: Medicare Secondary Payer booklet, including conditional payments.
• Medicare.gov: Who pays first?.
• Medicare.gov: End-Stage Renal Disease.
• CMS: Reporting other health insurance.
• CMS: Coordination of Benefits, including the BCRC’s role.
• CMS: Medicare Claims Processing Manual, Chapter 1, section 80.3.
• CMS: First-level redetermination.
• 42 CFR 405.942: Filing time frame.
• CMS: Medicare Advantage reconsideration.

Frequently Asked Questions