Reporting a WC Case

All WC occurrences that involve a Medicare beneficiary should be reported to the Benefits Coordination & Recovery Center (BCRC). If you are a Responsible Reporting Entity (RRE) making an initial report of ongoing responsibility, use the Section 111 COB Secure Website for reporting. For the submission of WCMSA information, contact the BCRC by phone or mail. Customer Service Representatives are available Monday through Friday, from 8:00 a.m. to 8:00 p.m., Eastern Time, except holidays. The BCRC’s toll free number is 1-855-798-2627 or TTY/TDD: 1-855-797-2627 for the hearing and speech impaired.

Written reports of WC occurrences should be addressed to:

Medicare—Medicare Secondary Payer
Medicare Secondary Payer Claims Investigation Project
P.O. Box 138897
Oklahoma City, OK 73113-8897

When contacting the BCRC to report a new WC occurrence by phone or by mail, please be sure to have the following information available:

• Injured person’s name
• Injured person’s Medicare ID (Health Insurance Claim Number [HICN] or Medicare
Beneficiary Identifier [MBI]) or Social Security Number (SSN)
• Date of incident
• Nature of illness/injury
• Name and address of the WC insurance carrier
• Name and address of the injured person’s legal representatives
• Name of insured
• Policy/claim number

Once this information is received, the BCRC will apply it to the beneficiary’s Medicare record and send it to the Commercial Repayment Center (CRC) for processing. The CRC will issue a Conditional Payment Letter (CPL) or Conditional Payment Notice (CPN) to the insurer, copied to the beneficiary, explaining Medicare’s recovery rights with respect to conditional payments and outlining next steps in the process. Please note that Medicare’s interests cannot be determined until the specifics of the WC occurrence are noted on the beneficiary’s record. For
inquiries after submission of the WC occurrence, beneficiaries and their representatives should contact the BCRC using the contact information above or in Appendix 1, and non-beneficiaries should contact the CRC at 1-855-798-2627 (TTY/TDD: 1-855-797-2627 for the hearing and speech impaired).

Medicare as Secondary Payer

“Medicare Secondary Payer” (MSP) is the term used when the Medicare program does not have primary payment responsibility on behalf of its beneficiaries—that is, when another entity has the responsibility for paying for medical care before Medicare. Until 1980, the Medicare program was the primary payer in all cases except those involving WC (including Black Lung benefits) or for care that is the responsibility of another government entity. With the addition of the MSP provisions in 1980 (and subsequent amendments), Medicare is secondary payer to group health plan insurance in specific circumstances, but is also secondary to liability insurance (including self-insurance), no-fault insurance, and WC. An insurer or WC plan cannot, by contract or otherwise, supersede federal law, for instance by alleging its coverage is “supplemental” to Medicare.

WC is a primary payer to the Medicare program for Medicare beneficiaries’ work-related illnesses or injuries. Medicare beneficiaries are required to apply for all applicable WC benefits.

If a Medicare beneficiary has WC coverage, providers, physicians, and other suppliers must bill WC first.

Outstanding WC Claims

If a Medicare beneficiary has outstanding WC-related claims that were not paid by either Medicare or the WC carrier prior to the settlement, the beneficiary is required to pay for related unpaid medicals bills out of his or her WC settlement. Medicare cannot pay because it is secondary to the WC settlement.

Conditional Primary Medicare Payments for Workers’ Compensation (WC), No-fault, and Liability Insurance

Frequently, there is a long delay between an injury and the decision by the primary payer, such as WC, no-fault, and liability insurance (including self-insurance), in contested compensation cases. Medicare may make conditional payments in such instances to avoid imposing a financial hardship on the provider and beneficiary awaiting a decision.

A conditional payment occurs where Medicare is not the primary payer, yet it makes a reimbursable payment on behalf of its beneficiaries for Medicare-covered services until the compensation case is resolved. Once the case is settled, Medicare has the right to recover any conditional Medicare payments.

MSP provisions allow conditional payments in certain situations when the primary payer has not paid or is not expected to pay within 120 days after receipt of the claim for specific items and/or services. Medicare makes these payments “on condition” that it will be reimbursed if it is shown another payer is primary. The conditional payment policy does not apply to Ongoing Responsibility for Medicals (ORM) benefits.

If there is a primary GHP, Medicare may not pay conditionally on the liability, no-fault, or WC claim if the claim is not billed to the GHP first. If GHP insurance exists for the beneficiary, it is important to bill the GHP insurance first, prior to billing the liability, no-fault, or WC insurer.

When a beneficiary has liability, no-fault, or WC coverage, Medicare may make conditional payments for claims when:

•Information on the claim or on Medicare’s Common Working File (CWF) indicates the liability, no-fault insurance, or WC is involved for that specific item or service
•No open GHP record is on the Medicare CWF MSP file as of the date of service
•Information on the claim indicates the physician, provider, or supplier sent the claim to the liability, no-fault insurer, or WC entity first
•Information on the claim indicates the liability, no-fault insurer, or WC entity did not pay the claim during the 120-day “paid promptly period” for reasons identified on the claim