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Jurisdiction 11 Part B
I received a primary payment from another insurer and a secondary payment from Medicare. Now we have too much money for that patient’s account. What should I do?

Answer:
In this scenario, it is likely that Medicare overpaid you. In this case, you must refund the additional money to Palmetto GBA. The most common cause of receiving too much money when two insurers are involved is due to not providing the Obligated to Accept as Payment in Full (OTAF) amount in a CAS segment using group code CO and the appropriate CARC code.

  • The OTAF field specifies when you are under contract with the primary insurer to accept a specified amount as 'payment in full.' This is similar to being a 'participating provider' with Medicare and your agreement to accept Medicare’s fee schedule or allowed amount as payment in full.
  • A good resource for understanding how to submit the OTAF amount on Medicare claims is available on our website: refer to 'Obligated to Accept as Payment in Full (OTAF)' under 'Browse by Topic', MSP
  • Refund the Medicare secondary payment to Palmetto GBA within 60 days of the date you identify the overpayment
    • Send a copy of the other insurer’s Explanation of Benefits (EOB) and the Overpayment Refund Form with your check. The Overpayment Refund Form is available on our website under 'Browse by Topic', Overpayments.
    • If you send a refund without the primary insurer’s EOB, Palmetto GBA may apply the refund to any other accounts receivables for that provider or provider group

 

last updated on 04/15/2014
ver 1.0.43