what must accompany a medicare secondary payer paper claim?

Paper claim submission 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.

Full Answer

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.

How do I get more information about Medicare Secondary Payer (MSP)?

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. You may keep hard copy files, optical images, microfilms, or microfiches.

Is Medicare always the secondary payer of benefits to non-group health plan?

We just addressed the fact that Medicare is always the secondary payer of benefits to Non-Group Health Plan insurance, and when certain conditions are met, the secondary payer to Group Health Plan insurance. If Medicare is not aware of other primary insurance, Medicare may mistakenly pay as primary.

What do you need to know about the Medicare econdary payer?

Medicare econdary Payer MLN Booklet Page 14 of 16 MLN006903 April 2021 Gathering Accurate Data You must determine if Medicare is the primary or secondary payer for each inpatient admission or outpatient encounter before submitting a Medicare claim. Ask patients about other coverage.

How does Medicare process secondary claims?

The insurance that pays first (primary payer) pays up to the limits of its coverage. 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.

Does Medicare accept secondary paper claims?

Currently, Medicare does not accept electronically filed claims when there is more than one payer primary to Medicare. Claims that involve more than one primary payer to Medicare must be submitted on the 1500 paper claim form, with all appropriate attachments.

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.

What is Medicare Secondary Payer Rule?

Generally the Medicare Secondary Payer rules prohibit employers with 20 or more employees from in any way incentivizing an active employee age 65 or older to elect Medicare instead of the group health plan, which includes offering a financial incentive.

Does Medicare accept paper claims?

The Administrative Simplification Compliance Act (ASCA) requires that as of October 16, 2003, all initial Medicare claims be submitted electronically, except in limited situations. Medicare is prohibited from payment of claims submitted on a paper claim form that do not meet the limited exception criteria.

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.

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 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.

When should MSPQ be completed?

every 90 daysAs a Part A institutional provider rendering recurring outpatient services, the MSP questionnaire should be completed prior to the initial visit and verified every 90 days.

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

0:239:21Medicare Secondary Payer (MSP) CMS-1500 Submission - YouTubeYouTubeStart of suggested clipEnd of suggested clipHere when the insured. And the patient are the same the biller enters the word. Same if medicare isMoreHere when the insured. And the patient are the same the biller enters the word. Same if medicare is primary this item is left blank.

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 .

Will secondary pay if primary denies?

If your primary insurance denies coverage, secondary insurance may or may not pay some part of the cost, depending on the insurance. If you do not have primary insurance, your secondary insurance may make little or no payment for your health care costs.

How to submit MSP claims?

MSP claims are submitted using the ANSI ASC X12N 837 format, or by entering the claim directly into the Fiscal Intermediary Standard System (FISS) via Direct Data Entry (DDE). If you need access to FISS in order to enter claims/adjustments via FISS DDE, contact the CGS EDI department at 1.877.299.4500 (select Option 2).

How to access MSP payment information?

Press F6 to access the "MSP Payment Information" screen for primary payer 2 (if there is one).

How to search for a CARC code?

You can also search through a list of CARC codes by accessing the FISS DDE Inquiry screen option 68 (ANSI REASON CODES) and type "C" in the RECORD TYPE field.

What is UB-04 in Medicare?

When a beneficiary is entitled to benefits under the Federal Black Lung (BL) Program, and services provided are related to BL, a paper (UB-04) claim must be submitted with MSP coding and the denial notice from the Federal BL Program. If applicable, also provide the workers' compensation insurer denial notice. If the services provided are not related to BL and does not include a BL related diagnosis code, the claim can be submitted via 5010 or FISS DDE showing Medicare as the primary payer.

Where is the CAS information on a claim?

This information is entered on the "MSP Payment Information" screen, which accommodates up to 20 entries for primary payer 1, and 20 entries for primary payer 2 (if there is one).

Can MSP claims be corrected?

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.

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.

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.

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:

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 is a COB in health insurance?

Coordination of Benefits (COB) allows plans to determine their payment responsibilities. The BCRC collects, manages, and uploads information to the Common Working File (CWF) about patients’ other health insurance coverage. Providers, physicians, and other suppliers must collect accurate MSP patient information to ensure that claims are filed properly.

How long does it take to pay a no fault claim?

For no-fault insurance and WC claims, “paid promptly” means payment within 120 days after the no-fault insurance or WC carrier got the claim for specific items and services. Without contradicting information, you must treat the service date for specific items and services as the claim date when determining the paid promptly period; for inpatient services, you must treat the discharge date as the service date.

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.

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.

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.

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.

What is Medicare Secondary Payer?

Medicare Secondary Payer (MSP) is a term used when Medicare is not responsible for paying first on a healthcare claim. The decision as to who is responsible for paying first on a claim and who pays second is known in the insurance industry as “coordination of benefits.”

What is Medicare data match?

This data match identifies persons that have had earnings in a given tax year. If a Medicare beneficiary and/or the spouse of a beneficiary has had earnings, that signifies employment, which means it is possible they also had Group Health Plan insurance coverage. A questionnaire is then sent to the employer inquiring about possible coverage that is primary to Medicare. If coverage exists or existed, dates of coverage are obtained, as well as the name and address of the insurer. Records obtained through this process are generally very reliable. 21

What is BCRC in Medicare?

The Benefits Coordination & Recovery Center (BCRC) consolidates the activities that support the identification, collection, management, and reporting of other primary insurance coverage for Medicare beneficiaries. They also collect and supply information on supplemental prescription drug coverage. The BCRC updates the Medicare systems with other insurance information.

What happens if a Medicare report is rejected?

If the record is rejected, the submitter is expected to research the record and submit a correction.

What is management of other insurance information?

Management of other insurance information is an ongoing process. Other insurance information for Medicare beneficiaries constantly changes. For example, Working Aged Medicare beneficiaries or their spouses retire, pending Liability cases get resolved, No-Fault insurance benefits become exhausted, and supplemental prescription drug coverage is dropped. All of these circumstances require updates to existing other insurance occurrences. All of the changes that occur must be updated on Medicare’s systems. The BCRC ensures appropriate updates are made to Medicare’s systems of records. 25

What is the purpose of coordination of benefits?

The purpose of Coordination of Benefits is to identify the other insurance benefits available to a Medicare beneficiary, and to coordinate the payment process to prevent mistaken payment of Medicare benefits.

What is a group health plan?

A Group Health Plan is health coverage sponsored by an employer or employee organization (such as a union) for a group of employees, and possibly for dependents and retirees as well. The term GHP includes self-insured plans, plans of government entities (Federal, State, and local), and employee organization plans such as union plans, employee health and welfare funds, or other employee organization plans. The term also includes “employee-pay-all” plans which receive no financial contributions from the employer. The term does not include self-employed persons. 7

Who is responsible for making sure their primary payer reimburses Medicare?

Medicare recipients may be responsible for making sure their primary payer reimburses Medicare for that payment. Medicare recipients are also responsible for responding to any claims communications from Medicare in order to ensure their coordination of benefits proceeds seamlessly.

What does a primary payer do?

In the simplest of terms, a primary payer will cover the cost of a health care bill according to its policy rules and up to the limit established therein.

How does Medicare work with insurance carriers?

Generally, a Medicare recipient’s health care providers and health insurance carriers work together to coordinate benefits and coverage rules with Medicare. However, it’s important to understand when Medicare acts as the secondary payer if there are choices made on your part that can change how this coordination happens.

What is ESRD covered by?

Diagnosed with End-Stage Renal Disease (ESRD) and covered by a group health plan or COBRA plan; Medicare becomes the primary payer after a 30-day coordination period.

How old do you have to be to be covered by a group health plan?

Over the age of 65 and covered by an employment-related group health plan as a current employee or the spouse of a current employee in an organization that shares a plan with other employers with more than 20 employees between them.

Is Medicare a secondary payer?

Medicare is the secondary payer if the recipient is: Over the age of 65 and covered by an employment-related group health plan as a current employee or the spouse of a current employee in an organization with more than 20 employees.

Who is covered by an employment-related group health plan?

Disabled and covered by an employment-related group health plan as a current employee or the spouse of a current employee in an organization that shares a plan with other employers with more than 100 employees between them.

What information is needed to bill MSP claims?

MSP claims require: • Medicare indicated as the secondary payer. • Insurance type. • Coordination of benefits (COB) payer paid amount.

What is CAS03 in insurance?

CAS03=’10’ actual adjustment amount. This is the difference between the billed amount (Loop 2400 SV203) and the primary insurance paid amount (Loop 2430 SVD02).

What is claim adjudication date?

The claim adjudication date is used to identify when the claim was adjudicated or paid by the primary payer and is required on MSP claims. Claim level information in the 2330 DTP should only appear if line level information is not available and could not be provided at the service line level (2430 loop).

When should service line adjudication information be provided?

Line adjudication information should be provided if the claim was adjudicated by the payer in 2330B NM1 and the service line has payment and/or adjustments applied to it. This information should be reported at the service level but may be reported at the claim level if line level information is unavailable. If the service line adjudication segment, 2430 SVD, is used, the service line adjudication date segment, 2430 DTP, is required.

When should a line adjudication date be reported?

The line adjudication date should be provided if the claim was adjudicated by the primary payer. This information should be reported at the service level but may be reported at the claim level if no line level payment or adjustments are reported.

What does SBR02 mean?

SBR02=‘18’ indicates self as the subscriber relationship code. The insurer is always the subscriber for Medicare.

Does Medicare accept electronic claims?

Currently, Medicare does not accept electronically filed claims when there is more than one payer primary to Medicare. Claims that involve more than one primary payer to Medicare must be submitted on the UB04 paper claim form, will all appropriate attachments. When billing Medicare as the secondary payer, the destination payer loop, ...

Submitting MSP Claims Via Fiss DDE Or 5010

Additional Information

Correcting MSP Claims and Adjustments

References