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Insurer/Third Party Administrator Services

Group Health Plans (GHPs), Third Party Administrators (TPAs), Liability and No-Fault Insurances, and Workers’ Compensation all have an obligation to ensure benefit payments are made in the proper order and to repay Medicare if mistaken primary payments are made or ifthere is a settlement, judgment, award or other payment made for services paid conditionally by Medicare. The Medicare program uses Coordination of Benefits (COB) processes to identify payers primary to Medicare and Medicare Secondary Payer recovery processes to recover mistaken primary payments and conditional payments.

Coordination of Benefits

The Benefits Coordination & Recovery Center (BCRC) consolidates the activities that support the collection, management, and reporting of other insurance coverage for Medicare beneficiaries. The BCRC takes actions to identify the health benefits available to a Medicare beneficiary and coordinates the payment process to prevent mistaken payment of Medicare benefits. The BCRC does not process claims or claims specific inquiries. The Medicare Administrative Contractors (MACs), Intermediaries and Carriers are responsible for processing claims submitted for primary or secondary payment.

When to Contact the BCRC:

The BCRC should be contacted to:

  • Report employment changes, or any other insurance coverage information
  • Report a liability, no-fault, or workers’ compensation case
  • Ask general Medicare Secondary Payer (MSP) questions
  • Ask questions regarding MSP Development letters and questionnaires

For additional information regarding Coordination of Benefits, go to the Related Links section at the bottom of this page and select Coordination of Benefits.

Medicare Secondary Payer Recovery

Medicare Secondary Payer (MSP) is the term used by Medicare when Medicare is not responsible for paying first. The MSP statute and regulations require Medicare to recover primary payments it mistakenly made for which a GHP is the proper primary payer.

If Medicare paid primary when the GHP had primary payment responsibility, Medicare’s Commercial Repayment Center (CRC) will seek repayment by issuing a recovery demand letter to the employer with a copy to the insurer or TPA, if known. The demand letter includes information on the claims repayment is demanded and the claims detail. The demand letter explains how to resolve the debt, either by repayment or presentation, and documentation of a valid defense. An employer may authorize an insurer or TPA to respond on its behalf, but may not transfer responsibility for a debt to the insurer or TPA. Additionally, if the insurer or TPA submits a check or a response but has not submitted documentation establishing its authority to act on behalf of the employer to resolve the debt, responses will only be addressed to the employer. Please note that in some instances an insurer or TPA has a defense that does not necessarily absolve the employer of responsibility for the debt (e.g., the insurer or TPA did not cover/administer at the time of the claim).

For more information on the processes used by the CRC to recover mistaken primary payments, go to the Related Links section at the bottom of this page and select the Group Health Plan Recovery link.

The MSP statute and regulation further preclude Medicare from paying for a beneficiary’s medical expenses when payment has been made, or can reasonably be expected to be made under workers’ compensation law or plan of the United States or under an automobile or liability insurance policy or plan (including a self-insured plan) or under no-fault insurance. However, the MSP provisions allow Medicare to pay conditionally for a beneficiary’s covered medical expenses when the third party payer does not pay promptly. If conditional payments are made, Medicare has the right to recover those payments. The BCRC is responsible for processing recovery cases involving liability insurance (including self-insurance), no-fault insurance and workers’ compensation.

For more information on the processes used by the BCRC to recover conditional payments, go to the Related Links section at the bottom of this page and select the Non-Group Health Plan Recovery link.

Mandatory Insurer Reporting

Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) (P.L.110-173) sets forth new mandatory reporting requirements for Group Health Plan (GHP) arrangements and for Liability Insurance (including Self-Insurance), No-Fault Insurance, and Workers' Compensation (also referred to as Non-Group Health Plans or NGHPs). See 42 U.S.C. 1395y(b)(7) & (8). The provisions were implemented January 1, 2009 for GHP arrangements, and July 1, 2009 for NGHP insurers.

For an overview of the Mandatory Insurer Reporting process, including registration and reporting requirements, please click the Mandatory Insurer Reporting for Group Health Plan (GHP) link or the Mandatory Insurer Reporting for Non-Group Health Plan (NGHP) link found in the Related Links section at the bottom of this page.

How to sign-up for Insurer/Third Party Administrator Service Web page updates

CMS provides the ability for you to be automatically notified when the changes are made to the Insurer/Third Party Administrator Services Web pages. If you have not already signed up for these notifications, please click the Sign-up for Insurer/Third Party Administrator Services Web Page Update Notification link found in the Related Links section below to subscribe. When notifications and new information are available, you will be notified via e-mail. Announcements regarding updates will also be posted to the Insurer/Third Party Administrator What’s New page.