Medicare_Carriers_Manual / 3110 / 3110

Why This Topic Matters

Correct claim routing affects whether a claim is returned, denied, forwarded, or processed by the appropriate Medicare entity. The article is relevant to organizations managing carrier jurisdiction, RRB-related claims, DMERC transfers, and HMO claim handling.

Article Sections

1. Disposition of Misdirected Claims

   Overview of how misdirected Medicare claims are handled and the scope of the guidance. The section distinguishes among different payer and jurisdiction scenarios.

2. A. A Local Carrier Receives a Claim with Some or All Services that are in Another Local Carrier's Payment Jurisdiction

   Guidance for claims sent to the wrong local carrier jurisdiction, including the associated remittance and notice messaging. The discussion also addresses how assigned and unassigned services are treated at a high level.

3. B. A Local Carrier Receives a Claim for an RRB Beneficiary

   Guidance for claims involving Railroad Retirement Board beneficiaries that are sent to a local carrier. The section includes general notice content and processing direction.

4. C. Requested Action When RRB Receives a Claim that is not for an RRB Beneficiary

   Requested handling when the RRB receives a claim that belongs elsewhere. The section addresses return and redirect expectations at a broad level.

5. D. Misdirected HMO Claims

   Reference to handling misdirected claims for HMO enrollees under separate Medicare manual guidance.

6. E. Transfer of Claims Between DMERCs

   General guidance for forwarding claims between DMERCs when a claim is submitted to the wrong processing entity. The section also notes timing considerations for processing.