Last Modified: 12/10/2016 Location: FL, PR, USVI Business: Part A
Limitations on ESRD coverage by certain health care plans
Many Medicare claims are denied because the beneficiary has another insurance that is primary to Medicare. However, there are different situations in which Medicare is the secondary payer (MSP). One of them is when a beneficiary is eligible for Medicare due to a diagnosis of end-stage renal disease (ESRD). These denials are reflected in your remittance advice with action code CO-22 (Payment denied because this care may be covered by another payer per coordination of benefits) and MOA code MA92 (missing/incomplete/invalid plan information for other insurance).
Beneficiaries eligible for Medicare due to ESRD are subject to a coordination period of 30 months regardless of the type of coverage available to the beneficiary. Once this period has ended, Medicare becomes the primary payer. During the coordination period, claims are submitted to the beneficiary’s primary payer for payment and then to Medicare with the explanation of benefit in order to be considered for secondary payment.
However, in those rare cases in which the beneficiary medical plan has a limited coverage or does not cover certain services, Medicare can pay the beneficiary’s services as primary. For instance, the beneficiary’s primary plan covers the first 90 days of dialysis treatment. In this situation, after this limitation is reached, Medicare may pay for these particular services as primary payer on a conditional basis and pay secondary on all other non-ESRD related services. Providers are required to submit evidence that the limitation has been reached so that Medicare can issue the corresponding payment. Claims meeting these criteria will need to be filed with specific information in order to avoid denials. Click here for information on how to submit a claim requesting a conditional payment for paper and electronic claims. In addition, providers will need to enter the following remarks "ESRD patient, 90 day limitation by insurer" on the “Remarks page 04” in direct data entry (DDE) or the electronic equivalent. Failure to add these remarks may cause the claim to be rejected.
On the other hand, some denials occur because records show that the coordination period has not ended although evidence available to provider indicates that it has. In those cases, providers are advised to contact the Benefits Coordination & Recovery Center (BCRC) -- 855-798-2627-- in order to have the beneficiary’s records updated. Once the records have been updated, claims can be resubmitted. Providers can also verify beneficiary’s eligibility, including MSP information, by contacting our interactive voice response system (IVR) at 1-877-847-4992.
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