May ,2000

June 1, 2001

Medi-989-01

TO: ALL MEDICARE PROVIDERS

SUBJECT: COORDINATION OF BENEFITS FACT SHEET

PRIMARY INTERESTS: BUSINESS OFFICE MANAGERS

Attached is a copy of the Health Care Financing Administration's Program Memorandum AB-01-76.

THIS BULLETIN SHOULD BE SHARED WITH ALL HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PROVIDER STAFF. NO COST COPIES ARE ALSO AVAILABLE FROM OUR WEB SITE AT riverbendgba.com

Please refer any questions to our office toll free at 877-296-6189.

Program Memorandum	Department of Health and Human Services (DHHS)
Intermediaries/Carriers	HEALTH CARE FINANCING ADMINISTRATION (HCFA)

Transmittal AB-01-76

Date: MAY 24, 2001

This Program Memorandum (PM) supersedes AB-00-129, dated December 19, 2000. Please discard AB-00-129 immediately.

CHANGE REQUEST 1460

SUBJECT: COB Contractor Fact Sheet for Providers

Background

On November 1, 1999, HCFA awarded the COB contract to consolidate activities that support the collection, management, and reporting of all other health insurance coverage for Medicare beneficiaries, as well as all insurance coverage obligated to pay primary to Medicare. On January 1, 2001, the COB contractor assumed all Medicare Secondary Payer (MSP) claims investigations as outlined in Program Memorandum (PM) AB-00-107, Change Request 1163 dated November 9, 2000 and PM AB-01-25, Change Request 1558 dated February 7, 2001.

Outreach to Providers

In an effort to prepare the provider community regarding the January implementation, every local Medicare intermediary and carrier (including DMERC) must release the attached fact sheet in their next upcoming provider bulletin release. The information contained in the fact sheet is a consolidated and uniform initial approach to outreach and educate the provider community. This education involves the transference of MSP prepay development work functions from the local intermediary and carrier to the COB Contractor, as well as those functions that will remain at the contractor sites. The attached information, less minimal modifications, was previously released an earlier version of this PM. Modifications have been made to the content to clarify issues that were unclear to the provider community. You should therein publish this information in its entirety, and you may not modify the content. In addition, the fact sheet should be posted to your web site.

Next Steps in Outreach and Education

You should continue to perform outreach and education as outlined in the FY 2001 Budget and Performance Requirements.

The effective date for this PM is April 1, 2001.

HCFA-Pub. 60AB

COB Contractor Fact Sheet for Providers

The Health Care Financing Administration (HCFA) has embarked on an important initiative to further expand its campaign against Medicare waste, fraud and abuse under the Medicare Integrity Program. HCFA awarded the Coordination of Benefits (COB) contract to consolidate the activities that support the collection, management, and reporting of other insurance coverage of Medicare beneficiaries.

The awarding of the COB contract provides many benefits for employers, providers, suppliers, third party payers, attorneys, beneficiaries, and Federal and State insurance programs. All Medicare Secondary Payer (MSP) claims investigations are initiated from, and researched at the COB contractor. This is no longer the function of your local Medicare intermediary or carrier. Implementing this single-source development approach will greatly reduce the amount of duplicate MSP investigations. This will also offer a centralized, one-stop customer service approach, for all MSP-related inquiries, including those seeking general MSP information, but not those related to specific claims or recoveries that serve to protect the Medicare Trust Funds. The COB Contractor provides customer service to all callers from any source, including but not limited to beneficiaries, attorneys/other beneficiary representatives, employers, insurers, providers, and suppliers.

Information Gathering

Medicare generally uses the term Medicare Secondary Payer or "MSP" when the Medicare program is not responsible for paying a claim first. The COB contractor will use a variety of methods and programs to identify situations in which Medicare beneficiaries have other health insurance that is primary to Medicare. In such situations, the other health plan has the legal obligation to meet the beneficiary’s health care expenses first before Medicare. The table below describes a few of these methods and programs.

*Method/Program*	Description
Initial Enrollment Questionnaire (IEQ)	Beneficiaries are sent a questionnaire about other insurance coverage approximately three (3) months before they are entitled to Medicare.
IRS/SSA/HCFA Data Match	Under the Omnibus Budget Reconciliation Act of 1989, employers are required to complete a questionnaire that requests Group Health Plan (GHP) information on identified workers who are either entitled to Medicare or married to a Medicare beneficiary.
MSP Claims Investigation	This activity involves the collection of data on other health insurance that may be primary to Medicare based on information submitted on a medical claim or from other sources.
Voluntary MSP Data Match Agreements	Voluntary Agreements allow for the electronic data exchange of GHP eligibility and Medicare information between HCFA and employers or various insurers.

Provider Requests and Questions Regarding Claims Payment

Intermediaries and carriers will continue to process claims submitted for primary or secondary payment. Claims processing will not be a function of the COB contractor. Questions concerning how to bill for payment (e.g., value codes, occurrence codes) should continue to be directed to your local intermediary or carrier. In addition, continue to return inappropriate Medicare payments to the local Medicare contractor. Checks should not be sent to the COB Contractor. Questions regarding Medicare claim or service denials and adjustments should continue to be directed to your local intermediary and carrier. If a provider submits a claim on behalf of a beneficiary and there is an indication of MSP, but not sufficient information to disprove the existence of MSP, the claim will be investigated by the COB Contractor. This investigation will be performed with the provider or supplier that submitted the claim. MSP investigations will no longer be a function of your local intermediary or carrier. The goal of MSP information gathering and investigation is to identify MSP situations quickly and accurately, thus ensuring correct primary and secondary payments by the responsible party. Providers, physicians, and other suppliers benefit not only from lower administrative claims costs, but also through enhanced customer service to their Medicare patients.

Medicare Secondary Payer Auxiliary Records in HCFA’s Database

The COB Contractor is the sole authority to ensure the accuracy and integrity of the MSP information contained in HCFA’s database (i.e., Common Working File). Information received as a result of MSP gathering and investigation is stored on the CWF in an MSP auxiliary file. The MSP auxiliary file allows for the entry of several auxiliary records, where necessary. MSP data may be updated, as necessary, based on additional information received from external parties (e.g., beneficiaries, providers, attorneys, third party payers). Beneficiary, spouse and/or family member changes in employment, reporting of an accident, illness, or injury, Federal program coverage changes, or any other insurance coverage information should be reported directly to the COB Contractor. HCFA also relies on providers and suppliers to ask their Medicare patients about the presence of other primary health care coverage, and to report this information when filing claims with the Medicare program.

Termination and Deletion of MSP Auxiliary Records in HCFA’s Database

Intermediaries and carriers will continue to terminate records on the CWF where the provider has received information that MSP no longer applies (e.g. succession of employment, exhaustion of benefits). Termination requests should continue to be directed to your local intermediary or carrier. MSP records on the CWF that you identify as invalid should be reported to the COB Contractor for investigation and deletion.

Contacting the COB Contractor

Effective January 1, 2001, refer all MSP inquiries; including, the reporting of potential MSP situations, invalid MSP auxiliary files, and general MSP questions/ concerns to the COB contractor. Continue to call your local intermediary and/or carrier regarding claims-related and recovery questions. The COB Contractor’s Customer Call Center toll free number is 1-800-999-1118 or TDD/TYY 1-800-318-8782. Customer service representatives are available to assist you from 8 a.m. to 8 p.m., Monday through Friday, eastern standard time, except holidays. Clip and post this section in a handy place for access by your office and billing staff.