Obtain billing information prior to providing hospital services. It is recommended that you use the CMS questionnaire, or a questionnaire that asks similar types of questions; and Submit any MSP information to the intermediary using condition and occurrence codes on the claim.
Full Answer
Is Medicare a secondary payer?
You must follow the MSP rules and bill Medicare as the secondary payer after the primary payer has made payment. We’ll inform you on your remittance advice how much you can collect from the patient after we make payment. NOTE: In situations where you’ve taken payment from a patient, they have the right to recoup
How to complete required Medicare questionnaire?
Medicare became secondary payer, it shall use that as the MSP effective date. If that information is not available, it shall use the Part A entitlement date as the MSP effective date. It may include a termination date when it initially establishes an "I" record. It may not add a termination date to an already established "I" record.
What is secondary payer?
20.1 - General Policy 20.2 - Verification of Medicare Secondary Payer (MSP) Online Data and Use of Admission Questions 20.2.1 - Model Admission Questions to Ask Medicare Beneficiaries 20.2.2 - Documentation to Support the Admission Process 30 …
How to deal with Medicare as a secondary insurance?
combined payment by a primary payer and by Medicare as the secondary payer is the same as or greater than the combined payment when Medicare is the primary payer. 10.1 - Working Aged (Rev. 106, 10-10-14, Effective: 01-01- 15, Implementation: 01-01-15) Medicare benefits are secondary to benefits payable under GHPs for individuals age 65
Is the MSP questionnaire required?
How often does the MSP questionnaire need to be completed?
What is the primary purpose of the Medicare Secondary Payer MSP questionnaire?
What is a Medicare Secondary Payer questionnaire?
What is MSP Medicare?
What is the policy when a Medicare patient Cannot recall their retirement date?
What is the main objective of the MSP questionnaire?
How can a provider ensure MSP is billed correctly?
How does Medicare Secondary Payer work?
What are the MSP codes?
| Value Code | Report with Amount Paid By | Payer Code |
|---|---|---|
| 13 | ESRD | B |
| 14 | No fault, Auto medical | D |
| 15 | Worker's Compensation | E |
| 16 | Federal Agency | F |
Is MSP required for Medicare Advantage plans?
How do I bill a MSP claim?
- Complete the claim form CMS-1500 or electronic equivalent in the usual manner.
- Report all claim coding usually required for the services including charges for all Medicare-covered services, not just the balance remaining after the primary payer's payment.
What is MSP in Medicare?
MSP provisions prevent Medicare paying items and services when patients have other primary health insurance coverage. In these cases, the MSP Program contributes:
What is Medicare Secondary Payer?
The Medicare Secondary Payer (MSP) provisions protect the Medicare Trust Fund from making payments when another entity has the responsibility of paying first. Any entity providing items and services to Medicare patients must determine if Medicare is the primary payer. This booklet gives an overview of the MSP provisions and explains your responsibilities in detail.
Why does Medicare make a conditional payment?
Medicare may make pending case conditional payments to avoid imposing a financial hardship on you and the patient while awaiting a contested case decision.
What happens if you don't file a claim with the primary payer?
File proper and timely claims with the primary payer. Not filing proper and timely claims with the primary payer may result in claim denial. Policies vary depending on the payer; check with the payer to learn its specific policies.
Does Medicare pay first when there is no fault?
no-fault pays first when there’s Ongoing Responsibility for Medicals (ORM) reported. Medicare doesn’t make a payment.
Can Medicare make a payment?
Medicare can’t make payment when payment “has been made or can reasonably be expected to be made” under liability insurance (including self-insurance), no-fault insurance, or a WC law or plan of the United States, called a primary plan.
Who pays first for Medicare?
Primary payers must pay a claim first. Medicare pays first for patients who don’t have other primary insurance or coverage. In certain situations, Medicare pays first when the patient has other insurance coverage.
What happens when the MSP effective date is not correct?
When this happens, the contractor shall advise the COB, via ECRS, of the need to change the MSP effective date and shall provide the COBC with documentation to substantiate the change.
What is the MSP Auxiliary File number?
As a result of MSP litigation settlement agreements CMS negotiated, records were added to the MSP Auxiliary file under contractor number 33333 (litigation settlement). Under the settlement agreements, CMS was to receive records for only those Medicare beneficiaries for which Medicare was secondary payer per a settlement agreement However, some data provided to CMS contain records for Medicare beneficiaries covered under a retirement group health plan or supplemental plan. These records were added to the CWF, MSP Auxiliary File. As these erroneous records are identified, beneficiaries, providers and the primary health plan have been notifying contractors that the records need to be corrected to again reflect Medicare as primary. All MSP Auxiliary File records, including these litigation records, need to be corrected and complete to maintain the integrity of the MSP Auxiliary File. As they become aware of an erroneous record, intermediaries and carriers are to advise the COBC via ECRS.
What is the CWF MSP data base?
The CWF MSP data base integrity is totally dependent upon COBC input, supported by input by FIs and carriers to the COBC. The COBC is responsible for submitting to CWF MSP information it believes to be of the highest quality. It shall investigate information thoroughly before making changes to an existing CWF MSP auxiliary record.
How many MSP records can be stored in CWF?
maximum number of 17 MSP auxiliary records may be stored in CWF for each beneficiary. The COBC is responsible for deletion of a record when the maximum storage is exceeded using the following priority:
Can a beneficiary have MSP?
An MSP situation cannot exist when a beneficiary has GHP coverage (i.e., working aged, disability and ESRD) and is entitled to Part B only. CWF will edit to prevent the posting of these MSP records to CWF when there is no Part A entitlement date. Currently, if a contractor submits an Electronic Correspondence Referral System (ECRS) transaction to the coordination of benefits (COB) contractor to add a GHP MSP record where there is no Part A entitlement, the contractor will receive a reason code of 61. The COB contractor's system cannot delete these types of records once the records are posted to CWF by a contractor. Beginning April 2002 CWF will create a utility to retroactively delete all MSP GHP records where there is no Part A entitlement.
Do non-lead contractors need to respond to ICN requests?
Non-lead contractors do not need to respond to ICN requests sent within the 18-month period. They should annotate such ICNs with the reason the ICN is not being processed and immediately return the ICN to the lead contractor (to ensure that the lead contractor can obtain the information from CWF while it is still available). If a non-lead contractor experiences repeated problems with this issue from a particular lead contractor, they should notify their regional office (RO).
How often do you need to collect MSP information?
Following the initial collection, the MSP information should be verified once every 90 days. If the MSP information collected by the hospital, from the beneficiary or his/her representative and used for billing, is no older than 90 calendar days from the date the service was rendered, then that information may be used to bill Medicare for recurring outpatient services furnished by hospitals. This policy, however, will not be a valid defense to Medicare’s right to recover when a mistaken payment situation is later found to exist.
When a provider receives a reduced no fault payment because of failure to file a proper claim, what is
When a provider receives a reduced no-fault payment because of failure to file a proper claim, (see Chapter 1, §20 for definition), the Medicare secondary payment may not exceed the amount that would have been payable if the no-fault insurer had paid on the basis of a proper claim.
Is GHP primary to Medicare?
Do you have employer group health plan (GHP) coverage through yourself, a spouse, or family member if dually entitled based on Disability and ESRD? If yes, the employer GHP may be primary to Medicare. Continue below.
Can a beneficiary recall his/her retirement date?
During the intake process, when a beneficiary cannot recall his/her precise retirement date as it relates to coverage under a group health plan as a policyholder or cannot recall the same information as it relates to his/her spouse, as applicable, hospitals must follow the policy below.
Does Medicare require independent labs to collect MSP?
The Centers for Medicare & Medicaid Services (CMS) will not require independent reference laboratories to collect MSP information in order to bill Medicare for reference laboratory services as described in subsection (b) above. Therefore, pursuant to section 943 of The Medicare Prescription Drug, Improvement & Modernization Act of 2003, CMS will not require hospitals to collect MSP information in order to bill Medicare for reference laboratory services as described in subsection (b) above. This policy, however, will not be a valid defense to Medicare’s right to recover when a mistaken payment situation is later found to exist.
Can you send a claim to Medicare with multiple primary payers?
Claims with multiple primary payers cannot be sent electronically to Medicare.
When will Medicare not pay a contractor?
The contractor will not make any Medicare payment if the beneficiary has not filed a claim or cooperated fully with the provider, physician or other supplier or the GHP. Also, the contractor will not make any Medicare payments until the beneficiary has exhausted the entire claims process. Conditional benefits are not payable if payment cannot be made under the GHP because the beneficiary failed to file a proper claim (See §20 for definition of proper claim) unless the failure to file a proper claim is due to mental or physical incapacity of the beneficiary. A beneficiary need not file any appeal if not inclined to do so.
What is the prohibition on Medicare?
An employer or other entity is prohibited from offering Medicare beneficiaries financial or other benefits as incentives not to enroll in or to terminate enrollment in a GHP or LGHP that is or would be primary to Medicare. This prohibition precludes the offering of benefits to Medicare beneficiaries that are alternatives to the employer's primary plan (e.g., prescription drugs) unless the beneficiary has primary coverage other than Medicare. An example would be primary plan coverage through his/her own or a spouse's employer. This rule applies even if the payments or benefits are offered to all other individuals who are eligible for coverage under the plan. It is a violation of the Medicare law every time a prohibited offer is made regardless of whether it is oral or in writing. Any entity that violates the prohibition is subject to a civil money penalty of up to $5,000 for each violation.
How long does a CMS hearing take?
Employer and employee organizations have 65 days from the date of their notice to request a hearing.
What age do you have to be to get Medicare?
Section 1862(b)(1)(A)(i)(II) of the Act provides that GHPs of employers of 20 or more employees must provide to any employee or spouse age 65 or older the same benefits under the same conditions that they provide to employees and spouses under 65 if those 65 or older are covered under the plan on the basis of the individual's current employment status or the current employment status of a spouse of any age. The requirement applies regardless of whether the individual or spouse 65 or older is entitled to Medicare.
Does GHP take into account Medicare?
GHP may not take into account that an individual is eligible for or entitled to Medicare benefits on the basis of ESRD during a coordination period described in Chapter 2,
Is John Jones a medicaid beneficiary?
John Jones, age 75, is a Medicare beneficiary with coverage under Part A and Part B. He retired from the Acme Tool Company in 2003 and received retirement health insurance coverage that is secondary to Medicare. His wife, Mary, age 64, has been employed continuously with the local police department since 1977 and since that time has received coverage for herself and her husband under the department's GHP. The priority of payment for John's medical expenses is as follows:
Is Medicare a secondary payer?
Medicare benefits are secondary payer to “large group health plans” (LGHP) for individuals under age 65 entitled to Medicare on the basis of disability and whose LGHP coverage is based on the individual’s current employment status or the current employment status of a family member. Under the law, a LGHP may not "take into account" that such an individual is eligible for, or receives, Medicare benefits based on disability. The instructions in §10.1 and throughout this manual that are applicable to GHPs are also applicable to LGHPs in processing claims where Medicare is secondary payer for disabled individuals. Where those sections refer to a GHP of 20 or more employees, substitute the term "large group health plan" as defined in §20, to apply them to disabled individuals.
Medicare Second Payer
Medicare Secondary Payer (MSP) is the term used by Medicare when Medicare is not responsible for paying first. (The private insurance industry generally talks about “ Coordination of Benefits ” when assigning responsibility for first and second payment.)
Precedence of Federal Law
Federal law takes precedence over State law and private contracts. Thus, for the categories of people described below, Medicare is the secondary payer regardless of state law or plan provisions. These Federal requirements are found in Section 1862 (b) of the Social Security Act {42 USC Section 1395y (b) (5)}.
Group Health Plans (GHP)
An employer cannot offer, subsidize, or be involved in the arrangement of a Medicare supplement policy where the law makes Medicare the secondary payer. Even if the employer does not contribute to the premium, but merely collects it and forwards it to the appropriate individual’s insurance company, the GHP policy is the primary payer to Medicare.
Responsibilities of Attorneys Under MSP
Immediately, upon taking a case, that involves a Medicare beneficiary, inform the COB Contractor about a potential liability lawsuit, and
Responsibilities of Insurers Under MSP
Report to the COB Contractor if you find that CMS has paid primary when you are primary to Medicare (i.e. 411.25).
Who may bill a GHP?
An MA organization may bill a GHP or LGHP for services it furnishes to a Medicare enrollee who is also covered under the GHP or LGHP and may bill the Medicare enrollee to the extent that he or she has been paid by the GHP or LGHP.
Can a state take away Medicare?
A State cannot take away an MA organization 's right under Federal law and the MSP regulations to bill, or to authorize providers and suppliers to bill, for services for which Medicare is not the primary payer. The MA organization will exercise the same rights to recover from a primary plan, entity, or individual that the Secretary exercises ...
How long does it take for a MSP to be posted to CWF?
Therefore, for the purposes of determining the promptly period (the 120 days ), Medicare contractors consider the date the liability record was created on Medicare's CWF to be the date the general liability claim was filed. Refer to article MM7355 ( Medicare Conditional Payment Policy and Billing Procedures for Liability, No-Fault and Workers' Compensation (WC) MSP Claims) for information on conditional payments and promptly situations. Additionally, please review your MAC's provider website for their MSP webpage, which contains a plethora of helpful information, tools and resources.
What is a CMS-1500?
The CMS-1500 (or the electronic equivalent) is the Part B claim form, which is used for billing MSP claims as well. Medicare guidance on completing the CMS-1500 can be found in the CMS IOM Publication 100-04, Chapter 26, Section 10.2 IOM Publication 100-04, Chapter 26, Section 10.2 . Additionally, your MAC may have information available on their ...
What is 42Q in Medicare?
42Q: If a provider wants to bill for a disabled beneficiary covered by a group health plan, and the diagnosis on the claim is not related to the disability, would the claim be billed to Medicare as primary?#N#42A: The GHP pays primary and Medicare pays secondary.
What is Medicare 60A?
60A: Medicare is the secondary payer to WC benefits when services rendered are related to the injury, illness or disease. If the patient does fall and the condition is unrelated to the WC condition, then you can submit the claim primary to Medicare as our system looks at the diagnosis codes.
Does Medicare have to report the amount paid by the primary insurer?
Report the amount paid by the primary insurer with appropriate coding on the claim. Medicare will process as secondary payer and the provider will need to contact the beneficiary for the primary payment resolution.
Can you file an MSP claim with Medicare?
52A: Yes. For inpatient services, if the primary payer made full payment (or an amount considered to be full payment), submit an MSP claim (known as an MSP no-payment claim or an MSP full-payment claim) to Medicare in even though there is no balance due from Medicare. This determines the benefit period.
Can a MSP file a lien?
6A: Yes, if State law permits. The MSP provisions do not create lien rights when those rights do not exist under State law. Where permitted by State law, a provider may file a lien for full charges against a beneficiary's liability settlement.