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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the MACs and legacy claims administration contractors must maintain a history file 
containing information about each claim processed.  The file may consist of the claim or information from it.  It 
must contain the following minimum information: 
Beneficiary HICN; 
Beneficiary name information; 
Provider identification (name or number); and  
Billing period from the claim 
 
Claims or claims information in the history file may be transferred to inactive files.  However, the MAC must 
have the facility to recall such claims or information if a claim for the beneficiary involving the same time 
period is received. 
 
Whenever any of the following claim situations occur, the MAC develops procedures to prevent duplicate 
payment of claims.  This includes, but is not limited to: Outpatient payment is claimed where the date of 
service is totally within inpatient dates of service at the same or another provider. Do not consider outpatient 
services provided on the day of discharge within the inpatient dates of service. Outpatient bill is submitted for 
services on the day of an inpatient admission or the day before the day of admission to the same hospital. 
Outpatient bill overlaps an inpatient admission period. Outpatient bill for services matches another outpatient 
bill with a service date for the same revenue code at the same provider or under a different provider number. 
 
1.  History File - Paid Claims 
The MACs and legacy claims administration contractors must maintain a history file containing information 
about each claim processed. The file may consist of the claim or information from it. It must contain the 
following minimum information: Beneficiary HICN; Beneficiary name information; Provider identification 
(name or number); and Billing period from the claim. Claims or claims information in the history file may be 
transferred to inactive files.  However, the MAC must have the facility to recall such claims or information if a 
claim for the beneficiary involving the same time period is received. 
 
2.  History File - Pending Claims 
Contractors must have controls to prevent a duplicate claim from being paid while two claims are in the 
process within the system at the same time.  This may be accomplished through a special check of in-process 
claims or in the history file for paid claims.  The file should contain the same minimum information indicated 
in the subsections below.  The check should be performed prior to sending the claim to CWF. 
 
3.  Analysis of Patterns of Duplicate Claims 
The contractors shall establish a system for continuing analysis of duplicate claims.  This includes the 
systematic evaluation of returned Medicare Summary Notices from beneficiaries and communications from 
providers indicating a duplicate payment has been made, as well as returned checks from any payee. The 
contractor's system should provide for analyzing duplicate claim receipts to determine whether certain 
providers are responsible for duplicates and, if so, identify those providers.  The contractor should educate such 
providers to reduce the number of duplicates they submit.  Should those providers continue to submit duplicate 
claims, the MAC should initiate program integrity action. B.  Claims Submitted by Physicians, Practitioners, 
and other Suppliers (except DMEPOS Suppliers) Claims or claim lines that have been determined to be exact 
duplicates of another claim or claim line are denied.  However, such denials may be appealed.  An exact 
duplicate for physician and other supplier claims submitted to a MAC or carrier is a claim or claim line that 
exactly matches another claim or claim line with respect to the following elements: HIC Number; Provider 
Number; From Date of Service; Through Date of Service; Type of Service; Procedure Code; Place of Service; 
and Billed Amount. 
 
You can find this information in the Medicare Claims Processing Manual Chapter 1 - General Billing 
Requirements. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.