BN - Medicare Data Match Process (Demand Letters)

This provides guidance on what steps an institution should follow if they receive a Medicare Demand letter and provides the process the UWSC will follow to respond to the Demand letter.

Procedure At-A-Glance
Category: Medicare Demand Letters
Audience: Benefit Administrators
Overarching Process: Benefits
Navigation: S: / UW Benefits > Medicare Data Match folder
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General Description

This provides guidance on what steps an institution should follow if they receive a Medicare Demand letter and provides the process the UW Service Center will follow to respond to the Demand letter.

Background - Centers for Medicare and Medicaid Services (CMS), Benefit Coordination & Recovery Center (BCRC) is the organization that oversees the Medicare Coordination of Benefits. 

The first step in the process is the Coordination of Benefits (COB) in which the BCRC works with Employee Trust Funds (ETF) for coordination of benefits to verify if Medicare is the primary or secondary payer.

  • IRS-SSA-CMS Data Match questionnaire is sent to ETF to complete coordinating coverage month data.
  • ETF responds through a Voluntary Data Sharing Agreement (VDSA) using the Electronic Media process to reply to the questionnaire.  

If BCRC determines after reviewing the data from the questionnaire that Medicare should have been the secondary payer, it will forward the claim for collection.  A Demand Letter will be sent to the employer (UW Service Center) and the health insurance carrier. We are allowed 60 days to resolve this issue. If the situation is not resolved, a second notice will be sent from the BCRC.

Process Inputs

  • Medicare Demand Letter
Process Outputs

  • Response to Demand letter

Process Considerations

  • Medicare should have been secondary if the employee had “Active Employee” health/prescription/major medical (EPIC now an indemnity payment since 2012) coverage.
  • The Health Insurance Claim Number (HICN) is the Social Security Number of the Beneficiary. (A beneficiary could also be the employee/subscriber)
  • The Third Party Payer is the Health Insurance Carrier


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    Procedure Steps

    Institution Process

    • If the Demand letter is received at the institutional level, please forward to the UW Service Center Benefits Team (Tier 3).  The UW Service Center will complete the processing.
    • If contacted directly by a health insurance carrier regarding a Demand Letter, please refer them to the UW Service Center Benefits Team.

    UW Service Center Process

    • Claim Management
      • Update the CMS Claims spreadsheet located in the Service Center Shared Drive: S: / UW Benefits > Medicare Data Match folder
      • Create a ticket in the Cherwell system – Short Description: Medicare Data Match
        • Employee name and ID
        • If the letter is for a beneficiary/dependent, use their name
        • Letter ID
        • PPN ID
        • Case ID
        • Campus/Institution
        • Health Plan(s) – Health, Navitus, or Major Medical

    • Print and scan any pertinent employee information to be added to the ticket.
      • Demand letter
      • ETF Previous Service screen print
      • MyETF One screen print
      • HRS employment documentation
      • EPM or UW legacy system information

    • Verify which institution the “Subscriber” works/worked at and add this information to the ticket.  Send an email via Cherwell informing the institution that a Demand Letter was received and the UW Service Center is processing it. Inform them if they are contacted by the health insurance carrier, to please forward all communications to the UW Service Center via the ticket.  All communications should be handled only by the UW Service Center.

    • Data match verification
      • Determine if the “Subscriber” is retired or still actively working.  Also verify that the “Subscriber” is not a Rehired Annuitant without WRS.
      • Verify whether or not the employee or beneficiary would have been under ‘Active Employee’ coverage or ‘Annuity’ coverage at the time of each claim/service date.
      • Using the documents listed above make these determinations.

    • If during the Data Match Verification it's determined that CMS has the incorrect information relating to when the “Subscriber” was covered under the “Active Employee” vs. the “Annuity” coverage; and in fact Medicare is the primary for COB purposes, the UW Service Center will have to prepare a letter to CMS/BCRC noting the discrepancy.  A copy of the letter must be provided to the health insurance carrier and attached to the ticket.

    •  If it is determined that CMS is correct and the employer (UW) is primary and we are responsible for the payment of the claim, the health insurance carriers are to handle repayment requests and respond directly to CMS/BCRC.
      • Review the Health Vendor list (provided by ETF) for the person that handles these claims at the vendor's office listed on the Demand Letter
      • Send an e-mail to the appropriate person at the insurance carrier indicating the claim, claim number, amount of the claim, and your determination as to who should be the rightful payer of the claims.  Be sure to include a copy of this e-mail in the ticket.
      • Copy Jennifer Lattis {} from UWSA Legal Counsel with this e-mail
      • Attach a copy of the Demand Letter to the e-mail.
      • Fill in the appropriate information to the CMS Claims spreadsheet
      • Once a final determination correspondence is received from the health insurance carrier or CMS, complete the information on the CMS Claims spreadsheet, attach the appropriate documentation with the ticket and close ticket.
    • Sample carrier email text:

      • We received the attached Medicare Data Match Demand letter regarding Medicare claims for EMPLOYEE NAME. In our research we find that the employee

        - is retired/terminated employment as of #/#/##. His employer health coverage ended #/#/##.  The claims listed were all obtained PRIOR TO/AFTER the employee coverage end date.
        -is still actively working as of #/#/## and is currently covered under our employer health coverage. The claims listed were all obtained WHILE COVERED UNDER THE/DURING A PERIOD WHEN THERE WAS NO employer health coverage.

        The employee carried the XXX Plan (single/family) health insurance.  Please verify that you have paid the claim in full.  If you need any further assistance please contact me.  Thank you.

      If a vendor has concerns regarding the sharing of information during the investigation or determination of a Medicare Data Match inquiry, the Department of Employee Trust Funds has a Sharing of Personal Health Information (PHI) agreement with the vendors. The Certificate of Disclosure of PHI at is available in the S > UW Benefits > Medicare Data Match folder and can be provided to the vendor if requested.

    • If an Intent to Refer Debt To Treasury notice is received, this indicates that the CMS is going to attach one of the future federal payment for the amount owing.  Verify that it is appropriate that we are being charged.  If not appropriate review history and see what step was not completed.  I.e.  Health provider never sent payment after we directed that they were liable for the service dates.  Or, the repeal letter was not received by CMS and needs resent. If it is appropriate that we owe these charges, work with Tami Eberle in UWSC Finance so she can help determine who at the institution needs to be involved should this happen to come out of any grant money.

    Related Policies, Job Aids and Forms

    Related Policies

    • Refer to the following ETF Employer Bulletins:

    Vol 32, No. 6, 4/30/2015
    Vol 21, No. 8, 6/17/2014
    Vol 25, No. 4, 3/24/2008  
    Vol 23, No. 13, 8/18/2006

    Related Job Aids

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    Related Forms

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      Keywords:Medicare, Data Match, Demand Letters, CMS, Benefit Coordination & Recovery Center, BCRC, Coordination of Benefits, COB,   Doc ID:52203
      Owner:Tina H.Group:Human Resource System (HRS)
      Created:2015-06-10 14:06 CDTUpdated:2016-08-08 13:36 CDT
      Sites:Human Resource System (HRS)
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