Gastroenterology Coding Alert

Question: We recently saw a patient with Tricare and Medicare, and we billed the claim to Tricare because we were told that Tricare is always primary, but the insurer denied the claim and said we should have billed it to Medicare. What has changed?

Codify Subscriber

Answer: The good news is that nothing has changed. The bad news is that although Tricare is usually the primary payer, that isn't true 100 percent of the time. In cases when the patient is no longer on active military duty and is seeing a civilian provider, then Medicare becomes the primary payer.

There are myriad situations that you may see when you have to determine whether Medicare is primary or secondary, but the following are among the most common scenarios you may encounter, according to CGS Medicare's Vanessa Williams, who spoke during the Part B payer's March 21 webinar, "Medicare Secondary Payer: The Basics."

Follow the first chart to find out when Medicare is typically primary and use the second chart to determine when Medicare is usually the secondary insurer.

MEDICARE IS PRIMARY:

• Patient is age 65 or older and covered by both Medicare and a group health plan for an employer with less than 20 employees.
• Patient is 65 or older and has a group health plan through her employer but is no longer working.
• Patient is under the age of 65 but entitled to Medicare, is disabled, is covered by a group health plan through an employer or a family member's employer, and the employer has fewer than 100 employees.
• Patient has end-stage renal disease and group health plan coverage, and 30 months of Medicare eligibility or entitlement have already passed.
• Patient has end-stage renal disease and COBRA coverage, and 30 months of Medicare eligibility or entitlement have already passed.
• Patient is age 65 or older OR disabled and is covered by both COBRA and Medicare.
• Patient is dual-eligible for both Medicare and Medicaid.
• Patient is covered by Medicare and also has a Medigap or supplemental insurance plan.
• Patient has both Tricare and Medicare but is on inactive military status and is being treated by civilian providers.

MEDICARE IS SECONDARY:

• Patient is age 65 years or older and is covered by both Medicare and a group insurance plan either through herself or a spouse; employer has 20 or more employees.
• Patient is under the age of 65 but entitled to Medicare, is disabled, is covered by a group health plan through an employer or a family member's employer, and the employer has 100 or more employees.
• Patient has end-stage renal disease and group health plan coverage and is still within her first 30 months of Medicare eligibility or entitlement.
• Patient has end-stage renal disease and COBRA coverage and is still within her first 30 months of Medicare eligibility or entitlement.
• Patient is entitled to Medicare but is being seen under workers' compensation coverage for a job-related illness or injury.
• Patient was in an accident and liability insurance is involved for the accident-related healthcare.
• Patient is an active duty military member entitled to both Medicare and Tricare.
• Patient is an inactive status military member entitled to both Medicare and Tricare being treated at a military hospital or by other federal providers.