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Last Modified: 2/2/2014 Location: FL, PR, USVI Business: Part A

Limitations on ESRD coverage by certain health care plans

At times, Medicare claims are denied because the beneficiary has another insurance that is primary to Medicare. These denials are reflected on 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). 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).
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 transpired, 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’s medical plan has a limited coverage or does not cover certain services, Medicare can make conditional payment for the beneficiary’s services. For example, the beneficiary’s primary plan covers the first 90 days of dialysis treatment. In this situation, after this limitation has been 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 retain evidence that the limitation has been reached so that Medicare can issue the corresponding payment. Click here for information on how to submit a claim requesting a conditional payment. 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.
Finally, some denials occur because records show that the coordination period has not ended although evidence is available to the provider indicates that it has ended. 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 877-847-4992 or by using our Secure Provider Online Tool (SPOT). Click here to learn more about SPOT.

First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.