Code of Federal Regulations Title 42. Public Health § 42.411.175 Basis for Medicare primary payments

(1) Furnished to Medicare beneficiaries who have declined to enroll in the GHP;

(2) Not covered by the plan for any individuals or spouses who are enrolled by virtue of the individual's current employment status;

(3) Covered under the plan but not available to particular individuals or spouses enrolled by virtue of current employment status because they have exhausted their benefits under the plan;

(4) Furnished to individuals whose COBRA continuation coverage has been terminated because of the individual's Medicare entitlement;  or

(5) Covered under COBRA continuation coverage notwithstanding the individual's Medicare entitlement.

(1) The beneficiary, the provider, or the supplier that has accepted assignment has filed a proper claim under the group health plan and the plan has denied the claim in whole or in part;  or

(2) The beneficiary, because of physical or mental incapacity, failed to file proper claim.

(1) The claim is denied for one of the following reasons:

(2) The group health plan fails to furnish information requested by CMS and necessary to determine whether the employer plan is primary to Medicare.