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Top Five Claim Denials and Resolutions – Medicare Secondary Payer Denials

The Remittance Advice will contain the following code when this denial is appropriate.

  • PR-22: Payment adjusted because this care may be covered by another payer per coordination of benefits

When is Medicare secondary?

  • Medicare may be secondary if the patient falls under any of the following reasons:

    MSP Type Secondary Coverage Reason
    Type 12 If the patient is an Aged Worker or Spouse with an employer group health plan of more than 20 employees
    Type 13 Is covered under an End State Renal Disease coordination period, which is typically the first 30 months
    Type 14 or 47 Is covered under a no-fault plan, which usually includes any liability or auto claims
    Type 15 Is covered under a workers' compensation claim
    Type 42 Is covered under a Veterans Administration plan and is not being attended within a VA facility or a VA physician
    Type 43 Is disabled and the employer's group plan has 100 or more employees

Resolution

The CGS Interactive Voice Response Unit (IVR) will need to be used to verify whether Medicare is primary or secondary for specific patients prior to submitting claims to Medicare.

If the patient's record does not match the information that Medicare provides, refer the patient to the Coordination of Benefits Contractor (COBC) to have his/her records corrected or for further determinations at (800) 999-1118, from 8 a.m. to 8 p.m. ET.  The COBC will have to correct/update the patient's insurance records in order for claims to be processed for payment.

If the records are correct, and your claims were denied please contact our Provider Customer Service department, and they will assist you.


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