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Home | Provider | Third Party Liability Coordination of Benefits | HMS - Medicare Disallowance Talking Points - March 2, 2011

HMS - Medicare Disallowance Talking Points - March 2, 2011

On March 2, 2011, the Department of Public Welfare's (Department) Division of Third Party Liability (TPL) issued a Medicare Part A TPL/Coordination of Benefits (COB) recovery through its TPL contractor, Health Management Systems, Inc. (HMS) related to claims originally paid by Medical Assistance (MA). The recovery was sent to provider type 01 (inpatient facility) only.  

• This TPL/COB Recovery Project encompasses recipients having Medicare coverage.

• TPL is seeking assistance from medical providers in recouping funds associated with recipients who had both Medicare and MA coverage at the time the service was delivered. The Department was not aware of the coverage at the time of service delivery.

• TPL and its contractor, HMS, are continually identifying resources via eligibility data exchanges with Medicare.  These are often identified after a claim is paid.  It is a Federal requirement that TPL recoup payments when a third party is identified. MA is to be the payer of last resort.

• The claims in this project cover dates of service associated with Medicare resources from February 2010 through July 2010.

• The letter to providers related to this recoupment project includes the following: two listings of the claims being considered for recoupment, instructions for responding to the TPL/COB Recoupment Project, and HMS contact information should the provider have questions.

• The letter also explains our expectation that the provider attempt to bill Medicare.  After the deadline date (60 days from the date of the letter), TPL will recoup the money electronically.  Providers are asked not to submit checks or payments as a result of any payments they receive from Medicare for the claims in this recoupment project, but they should supply documentation as explained in the project instructions to HMS to confirm receipt of denial from Medicare.

• Claims must be submitted to Medicare for processing within one year of date of service to be considered timely.

• If co-insurance and deductible amounts are due, the providers should submit a new claim for these payments to HMS according to the instructions included in the project. The new claim forms should be submitted only after the recovery has been completed. Providers will need to supply the ICN associated with the voided/retracted claim (ICN begins with Region Code '54') and the original ICN of the claim. Please send new billing forms only as the old forms will not be accepted.

• It is recommended that providers contact HMS at the toll-free number supplied in the instructions if they have questions regarding this project.