Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay 33 claims for medical services related to the automobile accident
rendered between October 28, 2022, to December 6, 2022.

You asked the Plan to pay for all services related to an automobile accident. You say that every single claim
should be covered as the only coverage you have is Medicare. The Plan denied your request. The Plan says
they could not pay for services possibly payable under an automobile insurance plan until they received a letter
from the auto insurer that all payment has been exhausted under their policy. Maximus overturned the Plans
denial for insufficient information in the case file as to what if anything was paid. The Plan requested a reopen
and provided additional information.

The Plan noted that on October 28, 2022, you sustained injuries following a motor vehicle accident. On
October 30, 2022, the Plan received the first of twenty (20) claims related to the motor vehicle accident, which
indicated the services provided therein were the result of a motor vehicle accident. On November 1, 2022, Plan
notified the injuries were related to a motor vehicle accident. In the denial of that initial claim, Plan informed
you that additional information, in particular the primary insurance information, was needed to process the
claim. The Plan informed you of the necessary next steps in notations on Explanations of Benefits (EOBs). The
Plan received an additional eight (8) claims related to a fall in your living facility on December 9, 2022. Upon
appeal, the Plan determined those claims were unrelated to a motor vehicle accident and paid those claims. The
records show you saw 12 providers on 20 occasions. All providers were in network, participating providers,
who have signed Plan's Provider Contract, which directs providers as to their responsibilities in instances of
Other Party Liability (OPL). In addition to the signed provider contracts between Plan and Ms. Shannon's 12
providers, each provider also received an Explanation of Payment (EOP), which conveyed the denial reasons:1)
that OPL was involved, and 2) additional information was needed from the enrollee before payment could be
made. On November 11th, 2022, Plan paid the claims related to the Motor Vehicle accident for dates of
service between October 28th, 2022, and December 9th, 2022, and submitted the claims to their
subrogation vendor to pursue repayment from the primary insurance plan.

Based on this new information, we are reversing our favorable decision made on May 23, 2023. The Plan must
follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee
has another type of insurance. This means that the Plan is not responsible for paying for services until the claim
for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits
with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the
Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to
send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for
reimbursement to the primary insurer.

Based on the information submitted with the reopen request, the Plan has met its obligation with regards to
coordination of benefits. Specifically, the Plan has paid for these services and submitted a bill to the primary
insurer. Therefore, we decided that the Plan does not have to pay for medical services related to the automobile
accident rendered between October 28, 2022, to December 6, 2022.