When a provider receives primary payments from Medicare and another insurer for the same service billed, the provider must repay the overpayment within 60 days of the receipt of the duplicate payment. 

The following steps will ensure proper correction to Medicare records and calculation of secondary payment is made.

The ADR/development letter is mailed to a provider’s practice address on file with Medicare. 

For individual providers rendering services in large facilities such as hospitals, the ADR letter may be misdirected and/or not received in a timely manner by the appropriate department and/or individual provider.

Providers in these situations may request First Coast to mail all correspondence (including ADRs) to the “pay-to” address listed on their Provider Enrollment, Chain and Ownership (PECOS) file.

The “incident to” provisions do not apply to hospital settings.

If the patient is enrolled in a Medicare Advantage plan (also known as a Medicare replacement plan), contact the Medicare Advantage plan prior to rendering services to determine what amount the patient is responsible for out of pocket. This will provide you guidance on whether to treat or bill the patient. Medicare does, however, limit the amount providers can bill patients for services. Refer to Medicare & You handbook more information.

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The Medicare secondary payment is determined by a series of calculations and comparisons. The primary insurer’s claim processing details on their explanation of benefits (EOB) is needed to determine the secondary payment amount.

Three calculations are made per procedure. The lowest of the three is the secondary payment. 

Calculation 1 

If the Obligated to Accept payment in Full (OTAF) amount is present, 

One of the provisions of the Balanced Budget Act (BBA) of 1997 (Section 4432b) requires consolidated billing for SNFs. The consolidated billing requirement confers on the SNF the billing responsibility for the entire package of care residents receive during a covered Part A SNF stay, as well as physical, occupational, and speech therapy services received during a non-covered stay.

While providers and facilities are required and expected to work together to resolve the billing issue, providers may occasionally require assistance from the MAC. In that case, First Coast will work with both the provider and the facility for resolution. In addition, when the overlapping claim is processed by another MAC, First Coast will work with that other MAC.

Complete and submit 'Request for Assistance Form'

You may request assistance from First Coast to resolve your overlapping claims. Please complete, print and fax:

What if you do not agree with First Coast's determination?