Reason Code 34545 - JF Part A

Reason Code Narrative

CLAIM SUBMITTED AS MEDICARE PRIMARY AND A POSITIVE WORKERS' COMP RECORD EXISTS AT CWF. THE CLAIM SHOULD BE BILLED TO THE WORKERS' COMP CARRIER. THE ORIGINATING CONTRACTOR IS '11122.' SERVICE IS WITHIN THE 120 DAY PROMPTLY PERIOD.

Common Reason Code Errors

• Claim was submitted as Medicare primary, however CWF shows an open workers' compensation record.

Common Reason Code Corrections

• Collect primary insurer information from beneficiary and resubmit claim electronically, with correct primary payer information and Medicare as secondary payer.
  • Workers Comp payments should be reflected with value code 15
  • Occurrence code 04 with date of accident or injury
• If claim is not related to open Workers' Compensation file, resubmit claim including detailed remarks explaining that claim is not related.
• If primary payer is denying payment on claim, resubmit claim including detailed remarks explaining why Workers Comp did not pay (benefits exhausted, not related, etc.).
• Conditional billing requires:
  • Occurrence code 24 with the date of insurer's denial
  • Medicare listed as secondary payer
  • Value code 15 with a $0.00 amount
  • Occurrence code 04

Note: Workers Comp payments should be reflected with value code 15 and occurrence code 04 with date of loss.

Resource

• CMS Internet Only Manual (IOM), Publication 100-05, Medicare Secondary Payer (MSP) Manual, Chapter 3

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