how to bill medicare secondary papyer claims

MSP billing. When Medicare is the secondary payer, submit the claim first to the primary insurer. The primary insurer must process the claim in accordance with the coverage provisions of its contract. If, after processing the claim, the primary insurer does not pay in full for the services, submit a claim via paper or electronically, to Medicare for consideration of secondary benefits.

Full Answer

How do I submit a paper claim to Medicare as secondary payer?

When submitting a paper claim to Medicare as the secondary payer, the CMS-1500 (02-12) claim form must indicate the name and policy number of the beneficiary's primary insurance in items 11-11c. For additional instructions on completing the CMS 1500 (02-12) claim form, please refer to the Completion of CMS 1500 (02-12) claim form.

When do you bill Medicare as the secondary payer?

When you find another insurer as the primary payer, bill that insurer first. (Page 16 of Chapter 3 of the Medicare Secondary Payer Manual provides guidance on finding other primary payers.) After receiving the primary payer remittance advice, bill Medicare as the secondary payer, if appropriate.

What is Medicare Secondary Payer (MSP)?

Medicare Secondary Payer (MSP) is the term generally used when the Medicare program does not have primary payment responsibility - that is, when another entity has the responsibility for paying before Medicare.

What is the primary payer for Medicare?

Medicare statute and regulations require that all entities that bill Medicare for items or services rendered to Medicare beneficiaries must determine whether Medicare is the primary payer for those items or services. Primary payers are those that have the primary responsibility for paying a claim.

How do I submit Medicare secondary payer claims?

Medicare Secondary Payer (MSP) claims can be submitted electronically to Novitas Solutions via your billing service/clearinghouse, directly through a Secure File Transfer Protocol (SFTP) connection, or via Novitasphere portal's batch claim submission.

What is the payer code for Medicare secondary?

Use payer code Z for Medicare. Payer codes (Code IDs): A = Working Aged beneficiary/spouse with an EGHP (beneficiary age 65 or over) – Beneficiary must be enrolled in Part A for this Provision to apply (VC 12) B = ESRD beneficiary with EGHP in MSP/ESRD 30-month coordination period (VC 13)

Does Medicare submit claims to secondary insurance?

Provider Central If a Medicare member has secondary insurance coverage through one of our plans (such as the Federal Employee Program, Medex, a group policy, or coverage through a vendor), Medicare generally forwards claims to us for processing.

What must be submitted when billing Medicare as the secondary insurance?

When Medicare is the secondary payer, submit the claim first to the primary insurer. The primary insurer must process the claim in accordance with the coverage provisions of its contract.

How do you fill out CMS 1500 when Medicare is secondary?

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What is MSP code G?

Primary Payer Code = G. 44. Amount provider was obligated/required to accept from a primary payer as payment in full due to contract/law when that amount is less than charges but higher than amount actually received. An MSP payment may be due.

How does Medicare Secondary Payer work?

The one that pays second (secondary payer) only pays if there are costs the primary insurer didn't cover. The secondary payer (which may be Medicare) may not pay all the remaining costs. If your group health plan or retiree coverage is the secondary payer, you may need to enroll in Medicare Part B before they'll pay.

When submitting a secondary claim what fields will the secondary insurance be in?

Secondary insurance of the patient is chosen as primary insurance for this secondary claim; primary insurance in the primary claim is chosen as secondary insurance in the secondary claim. Payment received from primary payer should be put in 'Amount Paid (Copay)(29)' field in Step-2 of Secondary claim wizard.

When would a biller most likely submit a claim to secondary insurance?

If a claim has a remaining balance after the primary insurance has paid, you will want to submit the claim to the secondary insurance, if one applies.

Is Medicare Secondary Payer questionnaire required?

CMS electronic tools help identify and verify MSP situations. Get more information in Medicare Secondary Payer Manual, Chapter 3, Section 20 or contact your MAC. Providers must keep completed MSP questionnaire copies and other MSP information for 10 years after the service date.

How do you know if Medicare is primary or secondary?

Medicare pays first and your group health plan (retiree) coverage pays second . If the employer has 100 or more employees, then the large group health plan pays first, and Medicare pays second .

What is the purpose of the Medicare Secondary Payer questionnaire?

CMS developed an MSP questionnaire for providers to use as a guide to help identify other payers that may be primary to Medicare. This questionnaire is a model of the type of questions you should ask to help identify MSP situations.

When is Medicare a secondary payer?

The primary insurer must process the claim in accordance with the coverage provisions of its contract. If, after processing the claim, the primary insurer does not pay in full for the services, submit a claim via paper or electronically, to Medicare for consideration of secondary benefits.

What is MSP in Medicare?

The MSP provisions apply to situations when Medicare is not the beneficiary’s primary health insurance coverage. Physicians, non-physician practitioners and suppliers are responsible for gathering MSP data to determine whether Medicare is the primary payer by asking Medicare beneficiaries questions concerning their MSP status.

Submitting MSP Claims via FISS DDE or 5010

All MSP claims submitted via FISS DDE or 5010 must report claim adjustment segment (CAS) information. In FISS DDE, the CAS information is entered on the "MSP Payment Information" screen (MAP1719), which is accessed from Claim Page 03 by pressing F11. This is in addition to the normal MSP coding information.

Correcting MSP Claims and Adjustments

Return to Provider (RTP): MSP claims may be corrected out of the RTP file (status/location T B9997). However, providers must ensure that claim adjustment segment (CAS) information is reported on the "MSP Payment Information" screen (MAP1719), accessed from Claim Page 03 by pressing F11.

Which line does Medicare enter information on?

If Medicare is the secondary or tertiary payer, the provider identifies the primary payer on line A and enters Medicare information on line B or C as appropriate. Please see IOM Publication 100-05, Chapter 5 , section 30.5 for specific tertiary guidelines.

When should VC 44 be reported?

The value code (VC) 44 is reported only if a provider is expecting to receive a payment after a primary payment has been made through a (preferred provider) contractual arrangement. The VC 44 should not be reported when: Providers have failed to file a proper claim to the primary payer.

Why are conditional payments referred to as conditional payments?

These payments are referred to as conditional payments because the money must be repaid to Medicare when a settlement, judgment, award, or other payment is secured. If the primary payer applied full or partial payment to deductible and coinsurance, it must be billed as a conditional payment.

What is condition code 77?

Condition code 77, full payment by primary insurance. This is entered when a provider accepts or is obligated/required due to a contractual arrangement or law to accept payment from the primary payer as payment in full. In this case, no Medicare payment will be made.

What is conditional payment?

A conditional payment is a payment made by Medicare for services on behalf of a Medicare beneficiary when there is evidence that the primary plan does not pay promptly. These payments are referred to as conditional payments because the money must be repaid to Medicare when a settlement, judgment, award, or other payment is secured.

Can a provider accept a primary payment?

Providers have failed to file a proper claim to the primary payer. Provider does not accept the primary payment as payment in full. Reminder: Providers are required to submit a covered claim for either determining the benefit period or for crediting the beneficiary’s Medicare deductible.

Is CPT copyrighted?

End User Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA).

Who must first bill the other insurance company before Medical Assistance will pay the claim?

If a recipient is covered by other insurance or third party benefits such as Worker’s Compensation, CHAMPUS or Blue Cross/Blue Shield, the provider must first bill the other insurance company before Medical Assistance will pay the claim. PROPER COMPLETION OF CMS-1500.

Do you need to complete 17-17B?

Required. Note: Completion of 17-17b is only required for Lab and Other Diagnostic Services.

Submitting MSP Claims Via Fiss DDE Or 5010

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Additional Information

Correcting MSP Claims and Adjustments

References