BCRC Training: Denied Claims and MSP Records

This set of vocabulary flashcards covers concepts related to Medicare primary and secondary payer scenarios, the causes of denied claims, and BCRC investigation procedures.

Denied Claim

A scenario resulting from Medicare being the incorrect primary payer or from anticipation that Medicare will deny a claim due to an open record on file.

BCRC

The entity responsible for identifying the issue a caller is having with a denied claim, educating them on the cause, and taking action on open MSP Records.

Claims Contractors

Entities responsible for processing all claims submitted by Durable Medical Equipment (DME) vendors.

Group Health Plan (GHP)

A type of insurance where Medicare pays secondary and may pick up the remainder of the medical charge; includes Working Aged, Disability, or ESRD records.

Non-Group Health Plan (NGHP)

A type of insurance where claims contractors compare diagnosis codes on the bill to diagnosis codes on the MSP occurrence to determine if Medicare should pay or deny.

Medicare Advantage Plans (Part C)

Plans where traditional Medicare is not primary and all claims must be submitted directly to the carrier.

L record

A Liability record that should not cause denied claims because accident-related treatment should be paid conditionally.

Provider Refusing to Bill

An issue occurring when a provider has provided treatment but refuses to bill Medicare due to anticipated claim denial.

Provider Refusing to Treat

An issue occurring when a provider refuses to treat a Medicare beneficiary for any treatment due to an open NGHP Record and anticipated claim denial.

Workers Compensation Set-Aside record

A record that may result in a denied claim if the claim is related to a specific injury or case.

DOI

Date of Incident; provided to the caller along with listed injuries to help them determine if they remember an incident.

Attestation

Documentation showing that benefits were exhausted, required to terminate a record if a claim is accident-related.

1-800-MEDICARE Referral

The recommended action for callers when a claim is not accident-related or when the caller has the information needed to resolve a status for a claim unrelated to an MSP case.

BCRS/HIMR

Systems used to review a beneficiary's records to ensure information on file is accurate and to identify open MSP screens.

MSP Record Detail

A section in BCRS containing coverage information such as Medicare Secondary Payer Type (e.g., Auto No Fault), Effective Date, and Termination Date.