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Question: One of our patients is 69 but their spouse is 63 and works for a mom-and-pop business with 16 other employees. Our 69-year-old patient has Medicare but also has coverage through their partner鈥檚 job. Do I submit a claim for an annual wellness visit (AWV) through Medicare or the other insurance?

Iowa Subscriber

Answer: If a patient has coverage through Medicare and an employer group health plan (GHP), then you need to look at some additional specific information before knowing who to bill as the primary payer. The main delineating information you need to know is how many employees work for the business offering the GHP.

The Centers for Medicare & Medicaid Services (CMS) says on their that Medicare would be the primary payer in this situation: 鈥�Individual is age 65 or older, is covered by a GHP through current employment or spouse鈥檚 current employment AND the employer has less than 20 employees: Medicare pays Primary, GHP pays secondary鈥� (emphasis original).

However, if the business providing the GHP employs more than 20 people, then the GHP would be the primary payer, and Medicare would be billed secondarily.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, 星空入口