How will I be reimbursed?

For workers’ compensation injuries, Ametros pays according to the lesser of Work Comp Fee Schedule and Medicare, or, according to PPO contracted rates depending on location.

What method of payment do you use to reimburse?

Ametros partners with third parties to assist with processing payment. We offer reimbursements through virtual credit card (VCC) and check.  For further information on reimbursement, please contact us directly.

Do you have timely filing?

No, CareGuard members are not bound by timely filing limits; however, we highly recommend billing in a timely manner as we cannot guarantee that a member’s settlement funds will not be exhausted at any given time.

Do I need to submit a Prior Authorization request?

We do not require prior authorization for any procedures, however, CareGuard is only able to pay for claims that are related to the member’s injury and Medicare compliant.  Additionally, a member is not guaranteed to have funds to cover a procedure just because they have coverage (please see what to do if you receive a funds exhausted EOR) We always recommend obtaining authorization from secondary insurance as back up and encourage you to speak with your patient about their fund status if you have any concerns.  CareGuard is unable to provide any fund amount to you directly.

Please be advised, CareGuard only provides prior authorizations for relatedness, compliancy, and fund availability.  We do not perform prior authorizations based on medical necessity.

My patient presented a CareGuard card, what does this mean?

CareGuard is Ametros’ professional administration service your patient has selected to manage their Medicare Set Aside (MSA) account. Your patient sustained a work related or liability injury, which they settled in court. Upon settlement, they were granted funds to pay for their future medical care related to this injury. From this point on, CareGuard should be billed as the primary payer for all claims related to this injury.

Is CareGuard the same as a Worker’s Compensation carrier?

No. CareGuard is not a Workers’ Compensation carrier. We are professional administrators of post settlement future medical funds. We do not require additional documentation or reporting and do not place restrictions on the frequency of doctor appointments. Our only requirements are that the member stays compliant within the constraints of their settlement documentation.

Do I have to accept payment from a Medicare Set Aside account?

Medicare is always secondary payer when the patient has received settlement funds for future medical from a Workers’ Compensation or liability settlement. According to Medicare, a Medicare Set Aside is the most frequently used method of protecting Medicare’s interest and preserving the funds for medical items and treatments related to the patient’s injury. For more information on what your patient can use their MSA on, see: Can I Spend my Medicare Set Aside Money?

Medicare recommends that Medicare beneficiaries:

“Should advise their health care provider about the existence of the MSA. They are also notified that their health care providers should bill them directly, and that they should pay those charges out of the MSA if:

  • The treatment or prescription is related to what was claimed or the settlement, judgment, award, or other payment had the effect of releasing AND
  • The treatment or prescription is something Medicare would cover

The obligation to protect the Medicare trust funds exists regardless of whether or not there is a formal CMS approved MSA amount. A Medicare beneficiary may or may not have documentation they can provide the physician, provider, or supplier from Medicare approving a Medicare Set-Aside amount.”

Medicare also advises providers to document their records when their patient states they are required to use funds from their settlement funds or Medicare Set Aside to pay for medical items and services related to their injury. Providers should accept payment from the professional administrator managing their Workers’ Compensation Medicare Set Aside (WCMSA) funds and not bill Medicare when a third party is administering the WCMSA funds.

Source: Accepting Payment from Patients with a Medicare Set-Aside Arrangement

What do you cover?

CareGuard is responsible for paying post-settlement claims related to your patient’s workers’ compensation or liability injury that are Medicare compliant.

How do I bill CareGuard?

CareGuard accepts claims typed on a CMS-1500 or UB-04.

When possible, we highly recommend submitting claims via our electronic payer ID, #20572.

Claims may also be mailed to the following address:

MSA CareGuard

PO Box 981609

El Paso, TX


Please note, we are unable to accept faxed claims and cannot guarantee processing if the claim is submitted this way.

What happens if I receive an EOR that says, “Funds Exhausted, Bill Secondary Insurance?”

CareGuard members receive a settlement fund for their work related or liability injury. Typically, members receive a seed amount to start their fund and then receive a yearly annuity. If a member exhausts their funds prior to receiving their next annuity payment, you will receive an Explanation of Reimbursement (EOR) stating “Funds Exhausted, Bill Secondary.”

At this point, you should contact your patient for secondary insurance information and resubmit the claim. If your patient has Medicare as their secondary insurance, you will need to submit the claim to Medicare with a copy of our EOR included. Please continue to submit all future bills to CareGuard even after receiving a Funds Exhausted EOR. This ensures that we will be able to supply you with the correct EOR documentation for Medicare (if necessary) and that we will seamlessly begin paying as primary once funds are replenished.

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