Defense Supporting Information & Documentation (What is this?)

This page allows you to review the requirements for documentation that must be submitted in support of your defense.

Information detailing which documentation is needed to defend all or part of Medicare’s demand is listed for the following defense types. A cover letter on debtor letterhead that explains the defense should be included with the defense submission.

Defending Claims in the Future or Making Payments
For claims you intend to defend in the future please wait to submit a defense. Unresolved claims will remain defendable until a debt is transferred to Treasury.
Payments that are made are not considered a defense. Please leave claims intended for payment blank.

About Supporting Documentation
For accuracy and improved timeliness of processing defenses, it is recommended that supporting documentation be specific to the individual defense and claims included in that defense. Identified debtors (employers, plan sponsors, insurers, or third-party administrators (TPAs)) may upload the same, consolidated, documentation package for each defense type asserted, but they must clearly indicate which documentation in the package supports which defense type.
If any information differs from what is on file with Medicare, for fastest resolution please contact the BCRC’s Customer Service Department at 855-798-2627 (TTY/TDD: 1-855-797-2627 for the hearing and speech impaired) and ensure that mandatory quarterly S111 reporting aligns with coverage being reported.

Defense Types

COV-Coverage: This defense type applies when one or more claims contained in Medicare’s demand are not for covered items or services according to the terms of the policy, or that the amount payable under the coverage was less than Medicare’s primary payment amount.
To defend all or part of Medicare’s demand, the following information must be submitted:

1. EOB, spreadsheet, or screen prints that include:
   • Beneficiary name
   • Subscriber name, if different from the beneficiary
   • Beneficiary's Medicare number (HICN or MBI)
   • Date(s) of service
   • Date the claim was paid, processed, check date
   • Total amount billed
   • Adjustments (co-pays, deductibles, provider discounts)
   • Proof of the denial of reimbursement for services not covered including the specific reason for the denial
   • Name of physician, provider, or other supplier to whom the payment was made
   • Copy of dated plan documentation or policy (screenshots are acceptable), for the year(s) of service, with applicable limitations and exclusions annotated, for the non-covered date of service/item. If the specific plan documents are not dated, an attestation on employer letterhead, certifying the validity of the submitted plan documents for the year(s) services rendered is acceptable.
2. Copy of plan documents or policy specific to the year services were rendered. These should be clearly marked to indicate the reason a service was not covered.
3. Any additional explanatory notes to assist in the review of the documentation.
   Note: The source of supporting evidence should be easily identifiable. If submission on letterhead or the like is not possible, an accompanying statement on debtor letterhead must certify the documents are from the appropriate source.
   When submitting plan documentation for the applicable plan year(s), limit the submission to relevant documentation only and annotate the specific area(s) that apply to the defense being asserted. If plan documentation for the applicable plan year is not available, an attestation is acceptable, provided it is on employer letterhead submitted by the employer. Alternatively, a copy of the employer’s attestation may be submitted by the insurer/TPA.

DCC-Payment applied to Deductible/Coinsurance/Copay: This defense type applies when the costs associated with claims included in the Medicare demand were applied to the deductible, coinsurance, copay, or other cost sharing under the terms of the GHP policy.
To defend all or part of Medicare’s demand, the following information must be submitted:

1. EOB, spreadsheet, or screen prints that include:
   • Beneficiary name and/or subscriber name, if different from the beneficiary
   • Beneficiary’s Medicare number (HICN or MBI)
   • Date(s) of service
   • Date the claim was processed
   • Total amount billed
   • Adjustments (co-pays, deductibles, provider discounts)
   • Proof of the denial of reimbursement for services not covered, including the specific reason for the denial
   • Provider name
2. Copy of plan documents or policy specific to the year services were rendered. These should be clearly marked to indicate the reason a service was not covered.
3. Any additional explanatory notes to assist in the review of the documentation.
   Note: The source of supporting evidence should be easily identifiable. If submission on letterhead or the like is not possible, an accompanying statement on debtor letterhead must certify the documents are from the appropriate source.
   When submitting plan documentation for the applicable plan year(s), limit the submission to relevant documentation only and annotate the specific area(s) that apply to the defense being asserted. If plan documentation for the applicable plan year is not available, an attestation is acceptable, provided it is on employer letterhead submitted by the employer. Alternatively, a copy of the employer’s attestation may be submitted by the insurer/TPA.
4. DIS - Disability: This defense type applies if Medicare is primary because the beneficiary is on long-term disability, and thus is no longer considered an active employee for purposes of qualifying for GHP benefits. The beneficiary must be on long-term disability for more than six (6) months for Medicare to assume primary payment responsibility. Medicare becomes the primary payer as the disability payments are no longer considered wages under the Federal Insurance Contributions Act (FICA).

To defend all or part of Medicare’s demand, the following information must be submitted:

1. Certification from the employer that the employee is not actively working and has been receiving disability benefits for more than six (6) months.
2. Beginning and end date (if applicable) of the long-term disability.
   Note: This information can be submitted on employer letterhead by the employer or by the insurer/TPA.

DPP - Duplicate Primary Payment / Capitation: This defense type applies when Medicare and an insurer both make primary payment for the same item or service (from the same provider, on the same date) listed on Medicare’s demand. The identified debtor may provide proof of its primary payment as a defense. Payment made under capitation arrangements also meet this definition.

In the event a duplicate primary payment defense is validated, the claim(s) will be referred to the applicable Medicare Administrative Contractor (MAC) for review and re-adjudication, where appropriate.

To defend all or part of Medicare’s demand, the following information must be submitted:

1. EOB, spreadsheet, or screen prints that include:
   • Beneficiary name and/or subscriber name, if different from the beneficiary
   • Beneficiary’s Medicare number (HICN or MBI)
   • Date(s) of service
   • Date the claim was processed
   • Total amount billed
   • Adjustments (co-pays, deductibles, provider discounts)
   • Proof of the denial of reimbursement for services not covered, including the specific reason for the denial
   • Provider name
2. Any additional explanatory notes or documentation to assist in the review of the defense, such as evidence of a capitation arrangement.
   Note: The source of supporting evidence should be easily identifiable. If submission on letterhead or the like is not possible, an accompanying statement on debtor letterhead must certify the documents are from the appropriate source.
   The debtor may not make primary payments to the provider, supplier, or beneficiary after receiving a Medicare demand letter in lieu of paying Medicare’s demand. Defenses that include payments made after the presumed receipt of the demand letter will be denied. Note that if the related coverage records submitted to Medicare were subsequently deleted, a Duplicate Primary Payment defense will be denied.

DUP - Duplicate Demand: Duplicative demand efforts may be encountered when an insurer or TPA erroneously deletes and resubmits coverage records through the Section 111 reporting process while a recovery case is in process. They may also occur when Medicare recovers its Duplicate Primary Payment from a provider (through voluntary refund, for example) soon before or concurrent with the issuance of the demand by the CRC.

To defend all or part of Medicare’s demand, the following information must be submitted:

1. An explanatory note identifying the claims for which Medicare was previously reimbursed, or which were successfully disputed and removed from a previous demand.
2. Evidence that Medicare was reimbursed for the claim or that the claim was removed from the recovery case, such as a copy of the Medicare Remittance Advice (RA) from the provider.

ELG – Eligibility: This defense type applies when a Medicare beneficiary did not have coverage under a GHP for all or some of the claims identified on Medicare’s demand. This defense is based on the beneficiary’s eligibility for coverage under the GHP based on their own, their spouse’s, or their family member’s employment status (such as when a beneficiary or subscriber retired, was not actively employed due to a leave of absence or did not have active coverage but was covered under a Consolidated Omnibus Budget Reconciliation Act (COBRA) policy).

To defend all or part of Medicare’s demand, the following information must be submitted:

1. Certification from the employer or other plan sponsor of the date the beneficiary or subscriber retired, was terminated, or otherwise became ineligible for health coverage benefits, or
2. Certification from the employer or other plan sponsor of the beginning and end date (if applicable) of either a leave of absence or COBRA coverage.
   Note: An insurer or TPA may provide this information on behalf of the employer, but the documentation must be on employer letterhead and signed by an authorized employer representative.
   If the beneficiary’s eligibility for coverage has changed due to long-term disability, please see the Disability (DIS) defense type.

EMP - Employer Size - Working Aged or Disabled

Employer Size Exclusion (Working Aged): This defense type may be asserted if a beneficiary with GHP coverage is entitled to Medicare on the basis of age (65 years old or older) and Medicare is primary to that GHP because the employer that sponsors or contributes to that GHP has fewer than 20 full and/or part-time employees for at least 20 weeks during the current and preceding year (the 20 weeks do not have to be consecutive).

This defense type may also be asserted where the GHP is a multi-employer plan and all participating employers that sponsor or contribute to that GHP have fewer than 20 full and/or part-time employees for at least 20 weeks during the current and preceding year.

To defend all or part of Medicare’s demand, the following information must be submitted:

1. To defend all or part of Medicare’s demand, the following information must be submitted:
   • Certification or other evidence that the employer did not participate in a multiple-employer GHP, and that the employer employed fewer than 20 employees for 20 weeks for each year and the preceding year that the beneficiary received services, OR,
   • If the employer participates in a multi-employer GHP, certification or other evidence that all employers in the plan had fewer than 20 full and/or part-time employees for 20 weeks for the current or the preceding year.

When an employer has fewer than 20 employees but participates in a multi-employer GHP where at least one other employer has more than 20 employees, the MSP rules apply to all individuals in the GHP who are entitled to Medicare based on age including those associated with any employers that have fewer than 20 employees. However, a multi-employer GHP may request an exception to the Working Aged MSP rules (“Small Employer Exception,” or SEE). If such an exception was requested and granted, please see below.

1. If the employer participated in a multiple-employer GHP and one employer in the GHP employed more than 20 employees, provide a copy of the approved SEE letter issued by the BCRC for that specific beneficiary.
   Note: SEEs are only applicable to individual beneficiaries and are prospective in nature, and so may only be used to dispute claims with dates of service after the SEE is granted. For more information regarding SEEs, please visit https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/EmployerServices/Small-Employer-Exception

Employer Size Exclusion (Disabled): This defense type may be asserted when a beneficiary with GHP coverage is entitled to Medicare on the basis of disability and Medicare is primary to the GHP because the employer that sponsors or contributes to that GHP has fewer than 100 full- and/or part-time employees for 50 percent or more of its business days for the preceding year.

To defend all or part of Medicare’s demand, the following information must be submitted:

1. If employer did not participate in a multiple-employer GHP and employed fewer than 100 employees for 50 percent of the year for each year and the preceding year that the beneficiary received services from MM/DD/YYYY to MM/DD/YYYY, OR,
2. If the employer did participate in a multiple-employer GHP, provide a statement that each participating group employed fewer than 100 employees for 50 percent of the year for each year and the preceding year that the beneficiary received services.
   Note: If the employer has fewer than 100 employees but participates in a multi- or multiple-employer plan and where at least one employer has 100 or more employees, this defense may not be asserted.
   When or if a beneficiary becomes entitled to Medicare on the basis of age in addition to disability, the Working Aged rules apply from the date of entitlement on the basis of age.

ESR - Medicare Primary Due to End of ESRD Coordination of Benefits Period: This defense may be asserted when a beneficiary is eligible for or entitled to Medicare due to End-Stage Renal Disease (ESRD) and the 30-month Coordination of Benefits (COB) period has elapsed. Medicare is the secondary payer for individuals eligible for or entitled to Medicare based on ESRD for the first 30 months of Medicare eligibility or entitlement, regardless of the number of employees and whether the coverage is based on current employment status. For more information regarding ESRD, please visit https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/End-Stage-Renal-Disease-ESRD/ESRD.

To defend all or part of Medicare’s demand, the following information must be submitted:

1. A clear explanation of why Medicare is primary for the claim(s) in question, based on the beneficiary’s ESRD diagnosis/treatment and dates of Medicare eligibility/ entitlement.
2. ESRD coverage start date.
   Note: When or if a beneficiary becomes entitled to Medicare on the basis of age and/or disability in addition to ESRD, the Working Aged and/or disability MSP rules apply from the date of entitlement on the basis of age and/ or disability.

IDT - Identity Theft Suspected: This defense type applies when the beneficiary did not receive the services on the claim(s) in question due to identity theft (also known as fraud and abuse).

To defend all or part of Medicare’s demand, the following information must be submitted:

1. An assertion that service(s) rendered were not received by the beneficiary.
2. The dates of service, provider name, and charged amounts that are being asserted to have not been received.
3. Any additional proof supporting the assertion of identity theft must be included, including but not limited to:
   • A police report;
   • Evidence the beneficiary was elsewhere at the time services were rendered, or otherwise unable to use the services (such as a timecard, or clear geographic distance);
     or
   • A letter from the beneficiary stating that the services were never rendered.

IND - Indian Health Services/Tribal Exclusion: This defense type may be asserted when a Medicare beneficiary has health coverage by merit of membership in a tribal organization (generally through tribal self-insurance). This defense type may also apply if claims included in the demand are for services the beneficiary received through an Indian Health Service (IHS) provider.

To defend all or part of Medicare’s demand, the following information must be submitted:

1. An assertion that service(s) rendered were provided by IHS.
2. Supporting documentation that the Medicare beneficiary is a member of a tribal organization.
   Note: If a member of a tribal organization has GHP health coverage through their own, their spouse’s, or their family member’s employment rather than membership in that tribal organization, then that employment-based health coverage is generally primary to Medicare and this defense type would not be appropriate.

INO - Patient Entitled to GHP Institutional Services Only: This defense type applies when a beneficiary was covered by a limited coverage plan that offers GHP Institutional services only. In this case, Medicare needs to verify that the beneficiary is covered by this plan type and services, as well as validate the Medicare coverage for the beneficiary to determine eligibility and enrollment.

To defend all or part of Medicare’s demand, the following information must be submitted:

1. Certification that the beneficiary was covered by a limited coverage plan, which offers limited benefits for institutional services only.

MAX - Service/Amount Maximum Per Year has been Met: This defense type applies when the benefit maximum for the year(s) of service was met for all or some of the claims on Medicare’s demand. A maximum benefit reached defense is appropriate when the payment for service(s) in question reaches an annual or lifetime benefit limit, as established within the plan or policy.

To defend all or part of Medicare’s demand, the following information must be submitted:

1. EOB, spreadsheet, or screen prints that include:
   • Beneficiary name and/or subscriber name, if different from the beneficiary
   • Beneficiary’s Medicare number (HICN or MBI)
   • Date(s) of service
   • Date the claim was processed
   • Total amount billed
   • Adjustments (co-pays, deductibles, provider discounts)
   • Proof of the denial of reimbursement for services not covered, including the specific reason for the denial
   • Provider name
2. Copy of plan documents or policy specific to the year services were rendered. These should be clearly marked to indicate the reason a service was not covered.
3. An accumulator must be provided as evidence for the proof that maximum benefits have been met.
4. Any additional explanatory notes to assist in the review of the documentation.
   Note: The source of supporting evidence should be easily identifiable. If submission on letterhead or the like is not possible, an accompanying statement on debtor letterhead must certify the documents are from the appropriate source.
   When submitting plan documentation for the applicable plan year(s), limit the submission to relevant documentation only and annotate the specific area(s) that apply to the defense being asserted. If plan documentation for the applicable plan year is not available, an attestation is acceptable, provided it is on employer letterhead submitted by the employer. Alternatively, a copy of the employer’s attestation may be submitted by the insurer/TPA.

NGH - Not a Group Health Plan: This defense type may be asserted when the information reported through the Section 111 process was incorrect, because the type of coverage did not meet Medicare’s definition of GHP coverage. If the coverage was reported in error, then the record must be deleted through the Section 111 reporting process. If the record is re-reported, additional recovery efforts may occur.

To defend all or part of Medicare’s demand, the following information must be submitted:

1. Evidence that the coverage was not GHP coverage as defined by Medicare when services were rendered (for example, coverage was an individual type of coverage such as a college student health coverage, short term/gap coverage paid for by beneficiary, life insurance, etc.).
2. The effective and termination dates of this coverage.

OTH - Includes the following three defense types:

Payment Made to Another Entity Defense: This defense type applies when payment has been issued but not received by the CRC. The payment may have been misdirected to another entity, such as the BCRC or the U.S. Department of the Treasury.

To defend all or part of Medicare’s demand, the following information must be submitted:

1. To whom payment was sent by the employer or insurer (name, address, etc.).
2. Payment information found on check (check date, amount, number, etc.).
3. Copy of the front and back of the check, if available.

Vow of Poverty Defense: This defense type applies when a beneficiary has taken a vow of poverty. A beneficiary in a religious order whose members are required to take a vow of poverty is not considered to have current employment status with the religious order if the services performed are considered employment for Social Security purposes only. A religious order that has elected Social Security coverage for its members under the Internal Revenue Service, Member of Religious Order Code, has eligibility and entitlement to Medicare. Under this circumstance, Medicare is considered the primary payer to any GHP coverage provided by the religious Order for a Medicare entitled member.

To defend all or part of Medicare’s demand, the following information must be submitted:

1. That the beneficiary is enrolled in Medicare due to age or disability.
2. The beneficiary has taken a vow of poverty.
3. The beneficiary is enrolled in the Social Security coverage under the Internal Revenue Service Member of Religious Order Code.
4. Confirmation the beneficiary has, or is performing services for the order, or at the direction of the order, for employer(s) outside of the order and the employer(s) does/do not provide insurance coverage.

Other: This defense type applies for any other reasons that the GHP is submitting a defense that does not match any of the previous definitions.

To defend all or part of Medicare’s demand, the following information must be submitted:

1. EOB, spreadsheet, or screen prints that include:
   • Beneficiary name and/or subscriber name, if different from the beneficiary
   • Beneficiary’s Medicare number (HICN or MBI)
   • Date(s) of service
   • Date the claim was processed
   • Total amount billed
   • Adjustments (co-pays, deductibles, provider discounts)
   • Proof of the denial of reimbursement for services not covered, including the specific reason for the denial
   • Provider name
2. Copy of plan documents or policy specific to the year services were rendered. These should be clearly marked to indicate the reason a service was not covered.
3. Any additional explanatory notes to assist in the review of the documentation.
   Note: The source of supporting evidence should be easily identifiable. If submission on letterhead or the like is not possible, an accompanying statement on debtor letterhead must certify the documents are from the appropriate source.
   When submitting plan documentation for the applicable plan year(s), limit the submission to relevant documentation only and annotate the specific area(s) that apply to the defense being asserted. If plan documentation for the applicable plan year is not available, an attestation is acceptable, provided it is on employer letterhead submitted by the employer. Alternatively, a copy of the employer’s attestation may be submitted by the insurer/TPA.

PBO - Patient Is Eligible for Medicare Part B Only: This very rare defense type only applies when a demand was erroneously generated. The GHP MSP rules do not apply where Medicare beneficiaries are eligible for Medicare Part B only. In this case, Medicare needs to be informed of the situation and validate the coverage for the beneficiary.

To defend all or part of Medicare’s demand, the following information must be submitted:

1. Explanation of the situation, including all relevant eligibility and coverage effective and termination dates.

PRE - Precertification/Preauthorization Not Filed: This defense type applies when the services were not covered due to failure by the beneficiary or subscriber to obtain prior authorization or pre-certification.

To defend all or part of Medicare’s demand, the following information must be submitted:

1. EOB, spreadsheet, or screen prints that include:
   • Beneficiary name and/or subscriber name, if different from the beneficiary
   • Beneficiary’s Medicare number (HICN or MBI)
   • Date(s) of service
   • Date the claim was processed
   • Total amount billed
   • Adjustments (co-pays, deductibles, provider discounts)
   • Proof of the denial of reimbursement for services not covered, including the specific reason for the denial
   • Provider name
2. Copy of plan documents or policy specific to the year services were rendered. These should be clearly marked to indicate the reason a service was not covered.
3. Any additional explanatory notes to assist in the review of the documentation.
   Note: The source of supporting evidence should be easily identifiable. If submission on letterhead or the like is not possible, an accompanying statement on debtor letterhead must certify the documents are from the appropriate source.
   When submitting plan documentation for the applicable plan year(s), limit the submission to relevant documentation only and annotate the specific area(s) that apply to the defense being asserted. If plan documentation for the applicable plan year is not available, an attestation is acceptable, provided it is on employer letterhead submitted by the employer. Alternatively, a copy of the employer’s attestation may be submitted by the insurer/TPA.

TIM - Timely Filing:

When Medicare’s demand is issued greater than three (3) years from a date of service an employer, insurer, or TPA may assert a Timely Filing Defense when certain criteria are met. To submit a possible Timely Filing Defense, there must first be certification that the GHP has no knowledge of the claim. “No knowledge” means that records do exist for the beneficiary but that no claim for services, whether primary, secondary, or tertiary, was ever presented. If a claim was ever presented by the provider, supplier, or beneficiary, whether or not it was paid or denied, then this defense type is inapplicable, and Medicare’s demand must be resolved.

When records do exist for the beneficiary but no record of a claim for the services may be located, then Medicare’s demand must be treated as a request for an appeal, or waiver, under the plan’s appeal or waiver rights. Under the plan’s appeal or waiver rights, the plan must treat Medicare’s demand with the same considerations as it would if the beneficiary had filed the appeal or request for waiver. A denial of an appeal or request for waiver must be justified by the plan’s established conditions for the year in which the services were provided. If a plan consistently rules in the beneficiary’s favor for timely filing appeals or waivers under subrogation rights, the plan also must rule in favor of Medicare’s demand.

A GHP is generally prohibited from asserting this defense type if the GHP in any way prevented Medicare from asserting its recovery claim within a reasonable amount of time relative to the date of service. Failure on the part of the GHP to report coverage to Medicare on time (i.e., within one year of the coverage effective date) prevents Medicare from asserting its recovery claim in a timely manner and would likely result in this defense being rejected.

The Balanced Budget Act of 1997 eliminated timely filing defenses for at least three (3) years from the date of service. For services on, or after, August 5, 1997, a Timely Filing Defense will not be accepted if Medicare’s original demand letter is dated within three (3) years of the date of service. This rule applies even if the plan’s timely filing period is less than three (3) years.

To defend all or part of Medicare’s demand, the following information must be submitted:

1. The beneficiary was a member of the GHP.
2. All records for the beneficiary were searched and no record of the services being provided was located.
3. Medicare’s demand was treated as a request for an appeal, based on the defense of Timely Filing and the appeal was denied, OR,
4. Medicare’s demand was treated as a request for waiver, based on the defense of Timely Filing and the waiver was denied, OR,
5. Appeal and/or waiver rights do not exist within the plan.
6. Plan documents for the year(s) the services were rendered that establish the timely filing plan provisions and appeal rights as applicable.

Notes:

The source and year(s) of supporting evidence should be easily identifiable. If submission on letterhead or the like is not possible, an accompanying statement on debtor letterhead must certify the documents are from the appropriate source and the year(s) in effect.

For any questions or concerns related to an MSP record report or acceptance date, please contact the BCRC EDI Department at 1-646-458-6740 or email the CRC at crcoutreachteam@performantcorp.com.

October 2022