Medicare Secondary Payer is the term generally used when the member has other primary insurance, such as group health plans and large group health plans. The decision as to who is responsible for paying first on a claim and who pays second is known as the coordination of benefits.
Alignment does not pay for services to the extent that there is a third party, which is required to be the primary payer. Providers shall bill the primary insurers first. Alignment pays up to the member's cost-sharing amount with Alignment. Alignment may make secondary payments if both of the following apply:
- The primary carrier payment is less than the gross amount payable by Medicare
- The provider does not accept and is not obligated to accept the primary carrier's payment as payment in full
In the case and presence of third-party liability (e.g., workers' compensation, no-fault, and liability insurance), Alignment makes conditional payments if the other insurance does not pay promptly. The conditional payments are subject to recovery when and if the other insurance does make payment.
All claim payments to providers are subject to retrospective review to determine whether any third-party liability exists and to recovery where such liability is determined to exist. Alignment may use a vendor to conduct a retrospective review on its behalf for third-party liability and recovery purposes.