MLN BookletMedicare Secondary Payer
MLN006903 October 2023Page 2 of 20
Table of Contents
What’s Changed? ................................................................................................................................ 3
MSP Provisions ................................................................................................................................... 4
When Medicare Pays First .................................................................................................................. 4
When We Don’t Pay Primary, Secondary, or Other .........................................................................11
MSP Provision Exceptions ................................................................................................................11
If the Primary Payer Denies the Claim ............................................................................................. 12
Conditional Payments ....................................................................................................................... 12
Collecting Patient Health Insurance Information ........................................................................... 14
Provider & Supplier Responsibilities .............................................................................................. 16
Submit Claims With Other Insurer Information .............................................................................. 18
File Proper & Timely Claims ............................................................................................................. 18
MSP Contact Information .................................................................................................................. 19
Resources .......................................................................................................................................... 20
MLN BookletMedicare Secondary Payer
MLN006903 October 2023Page 3 of 20
What’s Changed?
●
Added clarication for situations where a Group Health Plan (GHP) is the primary payer but
doesn’t pay in full for a service (page 5)
●
The Benets Coordination & Recovery Center (BCRC) and the Commercial Repayment Center
(CRC) are now referred to as the Medicare Secondary Payer (MSP) contractor (throughout)
●
Added clarication for situations where Medicare Administrative Contractors (MACs)
incorrectly deny claims because the services performed for an accident or injury aren’t related
to the liability, no-fault, or Workers’ Compensation MSP occurrence found on Medicare patient
records (page 9)
●
Added the address of where to send Federal Black Lung Program claims (page 11)
●
Added clarication about where to nd the claim adjustment segment and identifying the
correct claim adjustment reason code or we may deny the claim (page 12)
●
Added clarication about Ongoing Responsibility for Medicals (ORM), no-fault insurance
denials, and Medicare conditional payments (page 14)
●
Added clarication about provider responsibilities if they discover an MSP record for a patient
and how to bill appropriately (page 16)
Substantive content changes are in dark red.
MLN BookletMedicare Secondary Payer
MLN006903 October 2023Page 4 of 20
Medicare Secondary Payer (MSP)
provisions protect Medicare from
paying when another entity should
pay rst. Any entity providing items
and services to Medicare patients
must determine if Medicare is the
primary payer.
Stay Informed
To sign up for automatic updates regarding MSP or
Coordination of Benets (COB) issues, enter your email
address at the bottom of the Coordination of Benets &
Recovery Overview webpage.
MSP Provisions
The MSP provisions prevent Medicare from paying for items and services when patients have other
primary health insurance coverage. In these cases, the MSP provisions contribute to:
●
National program savings: MSP provisions saved the Medicare Program nearly $9.17 billion in
FY 2022.
●
Increased provider, physician, and other supplier revenue: Billing a primary plan before
Medicare means you may get better payment rates. Coordinated health coverage may speed up
the payment process and reduce administrative costs.
●
Avoiding Medicare recovery eorts: Filing claims correctly the rst time prevents future
Medicare claim recovery eorts.
To get these benets, it’s important to get correct and current patient health insurance coverage information
during the registration or admissions process. Medicare provisions require providers to determine the
primary or secondary payer of benets for patient items or services before submitting claims.
When Medicare Pays First
We (Medicare) pay rst for patients who don’t have other primary insurance or coverage primary
to Medicare. In certain situations, we may pay rst when the patient has other primary insurance
coverage. Situations where we pay rst include, but aren’t limited to:
●
The patient hasn’t met their primary payer deductible
●
The insurer doesn’t cover the service
●
The patient exhausted their insurance benets
Primary payers and settlement funds designed to cover all future services related to a settled injury or
illness (for example, Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA)) must pay
a claim rst.
In T
able 1 we list common situations when a patient has Medicare and other health insurance.
For each situation, we list which entity pays rst (primary payer) and the entity that pays second
(secondary payer).
MLN BookletMedicare Secondary Payer
MLN006903 October 2023Page 5 of 20
Table 1. Common MSP Coverage Situations
Patient Situation Pays First Pays Second
65 or older and has Group
Health Plan (GHP )
coverage through current
employment or spouse’s
current employment
*
Entitled to Medicare
Employer has less than
20 employees
Medicare GHP
65 or older and has GHP
coverage through current
employment or spouse’s
current employment
Entitled to Medicare
Employer has 20 or
more employees or
is part of a multiple or
multi-employer group
with at least 1 employer
employing 20 or more
people
GHP
Medicare
Note: If the GHP is
the primary payer
but doesn’t pay in
full, we may pay
secondary to cover
the remaining
amount the GHP
doesn’t pay if it’s a
service Medicare
covers. If the GHP
denies payment
because the plan
doesn’t cover the
service, we may
pay primary if
it’s a service
Medicare covers.
65 or older, has employer
retirement GHP coverage,
and isn’t working
Entitled to Medicare
Medicare
Retiree coverage
Under 65, disabled, and
has GHP coverage through
their current employment or
a family member’s current
employment
Entitled to Medicare
Employer has less than
100 employees
Medicare GHP
MLN BookletMedicare Secondary Payer
MLN006903 October 2023Page 6 of 20
Table 1. Common MSP Coverage Situations (cont.)
Patient Situation Pays First Pays Second
Under 65, disabled, and
has GHP coverage through
their current employment or
a family member’s current
employment
Entitled to Medicare
Employer has 100 or
more employees or
is part of a multiple or
multi-employer group
with at least 1 employer
employing 100 or
more people
GHP
Medicare
Federal Black Lung Program
(FBLP) coverage
Entitled to FBLP
coverage
Medicare covers
services or items not
related to the Black
Lung diagnosis
FBLP
Medicare
ESRD and GHP coverage
was primary before the person
became eligible or entitled to
Medicare based on
ESRD diagnosis
Before 30 months of
Medicare eligibility
or entitlement
GHP
Medicare
ESRD and has GHP coverage After 30 months of
Medicare eligibility
or entitlement
Medicare GHP
ESRD and Consolidated
Omnibus Budget
Reconciliation Act (COBRA)
coverage before the person
became eligible or entitled to
Medicare
First 30 months of
Medicare eligibility
or entitlement
COBRA
Medicare
ESRD and has
COBRA coverage
After 30 months of
Medicare eligibility
or entitlement
Medicare
COBRA
MLN BookletMedicare Secondary Payer
MLN006903 October 2023Page 7 of 20
Table 1. Common MSP Coverage Situations (cont.)
Patient Situation Pays First Pays Second
Parts A and B coverage under a
Medicare Advantage (MA) Plan
Also has a GHP Health
Reimbursement Account
(HRA)
Contact MA Plan for
billing guidance.
None (employer
pays person from
HRA for out-of-
pocket expenses)
**Workers’ Compensation
(WC) coverage because of
job-related illness or injury
Entitled to Medicare
WC pays health
care items or job-
related illness or
injury services rst
(see the Conditional
Payments section).
When a WC case
settles, a WCMSA
may substitute for
WC coverage.
Medicare
**In an accident or other
incident, including auto
accidents, where there’s
no-fault or liability insurance
Entitled to Medicare
No-fault or liability
insurance pays
accident- or other
incident-related
health care
services rst
(see the Conditional
Payments section).
WC, liability, or
no-fault pays rst
when the Responsible
Reporting
Entities (RREs)
report Ongoing
Responsibility for
Medicals (ORM).
Medicare doesn’t pay.
Accident
Medicare
Note: For ORM,
Medicare doesn’t
pay until ORM
funds exhaust.
MLN BookletMedicare Secondary Payer
MLN006903 October 2023Page 8 of 20
Table 1. Common MSP Coverage Situations (cont.)
Patient Situation Pays First Pays Second
**In an accident or other
incident where there’s
no-fault or liability insurance
Patient has no-fault or
liability insurance but
refuses to give
the information
Determination
happens after
submitting the claim
to Medicare. The
MSP contractor
works with the
patient to determine
who’s the primary
payer. We also nd
out who’s primary
through Section 111
reporting.
To be determined
65 or older, or disabled and
has Medicare and COBRA
coverage
Entitled to Medicare
Medicare
COBRA
Dually eligible patient
regardless of eligibility reason
Enrolled in Medicare and
Medicaid
Medicare
Medicaid
Has Medicare coverage
and a Medicare supplement
insurance (Medigap) plan
Entitled to Medicare
Medicare
Medigap
Active-duty status
military member
Entitled to Medicare
and TRICARE
TRICARE
Medicare
MLN BookletMedicare Secondary Payer
MLN006903 October 2023Page 9 of 20
Table 1. Common MSP Coverage Situations (cont.)
Patient Situation Pays First Pays Second
Inactive status military
member treated by
civilian providers
Entitled to Medicare
and TRICARE
Medicare
TRICARE
Inactive status military
member treated at a
military hospital or by
other federal providers
Entitled to Medicare
and TRICARE
TRICARE
Medicare
* A GHP is any arrangement of, or contribution from, 1 or more employers or employee organizations providing insurance
to current or former employees or their families.
** A Non-Group Health Plan (NGHP) is liability insurance coverage (including self-insurance), no-fault insurer, and WC.
Submit all NGHP claims to the NGHP insurer before submitting claims to Medicare.
Medicare Administrative Contractors (MACs) may incorrectly deny claims because the services
performed for an accident or injury aren’t related to the liability, no-fault, or WC MSP
occurrence
found on the patient’s eligibility le. Although claim services aren’t related to the accident or injury, the
provider may use diagnosis codes on the claim that are within the family of diagnosis codes found on
the Medicare eligibility le.
You may appeal these incorrectly denied claims. If you appeal the claim, you must provide information
that proves the services didn’t relate to the accident or injury. Continue providing services to the
patient during your appeal period if there’s an open MSP record found on the Medicare eligibility le
or if you’re still waiting for payment on previous submitted claims.
MLN BookletMedicare Secondary Payer
Page 10 of 20 MLN006903 October 2023
ESRD-MSP Rules & Dually Entitled Patients
A patient meets dual entitlement when they’re eligible or entitled to Medicare based on ESRD, age,
or disability.
If we’re the primary payer based on entitlement due to age or disability and the patient doesn’t have
GHP coverage, we remain the primary payer during and after the 30-month ESRD coordination period.
We pay rst when we’re the only payer upon the patient’s entitlement to ESRD or if we’re legally
required to pay primary to any GHP coverage. Otherwise, we pay secondary to any GHP coverage that
may exist during the ESRD coordination period.
Table 2. ESRD-MSP Rules
Basis of Medicare Eligibility &
Group Health Plan Coverage
Application of Rule
ESRD only Medicare pays secondary to any GHP coverage
Age or disability entitlement and GHP coverage
comes before ESRD eligibility with Medicare
being primary
Medicare pays primary to any GHP coverage
Age or disability entitlement and GHP coverage
comes before ESRD eligibility with Medicare
being secondary
Medicare pays secondary to any GHP coverage
Age or disability entitlement and ESRD
eligibility occur on the same day
Medicare pays secondary to any GHP coverage
at the time of ESRD eligibility or after the
patient gets ESRD eligibility
ESRD eligibility comes before entitlement
based on age or disability
Medicare pays secondary to any GHP coverage
Age or disability entitlement and no GHP
coverage comes before ESRD eligibility
Medicare pays primary to any GHP coverage
MLN BookletMedicare Secondary Payer
Page 11 of 20 MLN006903 October 2023
When We Don’t Pay Primary, Secondary, or Other
Veterans Benets
We don’t pay (primary, secondary, or otherwise) for services authorized under Veterans Health
Administration (VHA) benets. However, we may cover and pay for services not authorized under
VHA benets. Both Medicare and and the U.S. Department of Veterans Aairs (VA) may recover
duplicate payments in situations where both agencies made payments on the same claim services.
Return Medicare’s payment for services that the VA paid, as this is considered a duplicate payment.
The VA is a government-run military system that administers veterans’ benets and provides veterans’
health care coverage through the VHA. The program oers people who serve or formerly served in
the Armed Forces primary care, specialized care, and related medical and social support services.
Federal Black Lung Program Benets
We don’t pay (primary, secondary, or otherwise) for
FBLP-covered services. If a patient has an illness
or injury unrelated to Black Lung, we may pay
claims. Under rare circumstances, we may pay on
Black Lung claims if the FBLP denies the service
or the Department of Labor denies full Black Lung
payments. We may make Medicare payments on a
case-by-case basis. We can recover duplicate claims.
Mailing FBLP Claims
U.S. Department of Labor OWCP/DCMWC
P.O. Box 8307
London, KY 40742-8307
MSP Provision Exceptions
There aren’t exceptions to the MSP provisions. Section 1862(b)(2)(A)(i) of the Social Security Act and
42 United States Code 1395(y)(b)(2)(A)(i) prohibit accepting patient service payments on admission if
they have another primary insurance. If you do this, you must stop immediately.
Participating Medicare providers, physicians, and other suppliers must not accept any copayment,
coinsurance, or other payments from the patient when the primary payer is an employer Managed
Care Organization insurance or any other type of primary insurance, like an employer GHP.
You must follow the MSP rules and bill Medicare as the secondary payer after the primary payer
makes payment. Your remittance advice will show how much you can collect from the patient.
Note: In situations where patients made payment, they have a right to a refund and you must
reimburse them.
MLN BookletMedicare Secondary Payer
Page 12 of 20 MLN006903 October 2023
If the Primary Payer Denies the Claim
We may pay, assuming the service is Medicare-covered and payable and the provider les a proper
claim, in these situations:
●
The no-fault or liability insurer doesn’t pay during the paid promptly period or denies the medical
bill. We don’t pay for services that relate to an accident when there’s an open ORM or set-aside
record for services that relate to an accident.
●
The WC program doesn’t pay during the paid promptly period or denies payment (for example,
when the WC claim excludes a medical condition or certain services). Providers must give the
reason for denial on Medicare claims.
●
The patient gets services that don’t relate to the accident or injury.
●
WCMSA funds or the ORM benets terminate or exhaust.
●
The GHP denies service payment because:
●
The patient hasn’t met their GHP deductible
●
The patient exhausted certain plan benet services
●
The patient isn’t enrolled for GHP benets
●
The patient needs services the GHP doesn’t cover
When submitting an MSP claim, explain why the other payer denied the claim, made an exhausted benets
determination, didn’t pay the claim in full, or another reason why the primary payer didn’t pay the claim. You
can nd the claim adjustment segment on ASC X12 835 remittance advice or ASC X12 837 professional
claim. You need to identify the correct claim adjustment reason code or we may deny the claim.
We can’t pay claims that were already paid or if we can reasonably expect the no-fault insurance,
liability insurance (including self-insurance), WC plan, or GHP primary plan to make payment.
Medicare and federal laws, including the MSP provisions, take priority over state law or an
insurance policy’s contents. Section 1862(b) of the Social Security Act establishes payment order and
takes priority over state laws and private contracts.
Conditional Payments
In contested compensation cases, there’s often a long delay between an injury and the primary
payer decision. We may make pending case conditional payments, for non-ORM situations, to avoid
imposing a nancial hardship on you and the patient while awaiting a contested case decision. We
won’t make conditional Medicare payments when ORM applies and there’s an open ORM record on
the patient’s Medicare record.
We can make conditional covered service payments even if we aren’t the primary payer. We may
make conditional covered service payments in non-ORM liability (including self-insurance), no-fault,
and WC situations if the following apply:
MLN BookletMedicare Secondary Payer
Page 13 of 20 MLN006903 October 2023
●
Liability, including self-insurance, no-fault, or WC has payment liability and responsibility
●
We don’t expect a prompt payment
When a patient has non-ORM liability, no-fault, or WC coverage, we may make conditional claims
payments when:
●
The claim information or the Common Working File (CWF) shows liability, no-fault insurance, or a
specic item or service with WC involvement
●
There’s no open GHP CWF MSP le record for the service date
●
The claim information shows the physician, provider, or supplier sent the claim to the liability,
no-fault insurer, or WC entity rst
●
The claim information shows the liability, no-fault insurer, or WC entity didn’t pay the claim during
the 120-day paid promptly period for identied reasons
Always send the claim to the primary payer rst. If the primary payer denies the claim because of
liability, the no-fault or WC insurer must place the reason for denial on the claim, which you can nd
on your remittance advice that you’ll send to Medicare. Without this reason, Medicare will deny the
claim. If this is a non-ORM situation and the claim is less than 120 days past the date of service,
Medicare may make a payment on the claim. You can nd electronic remittance advices and reasons
for claim denial in the claim adjustment segment. We can recover any conditional payments. The
MSP contractor recovers conditional payments from the patient or that person’s attorney if the patient
gets a settlement, judgment, award, or other payment.
We may pay for conditional primary benets if the provider, physician, supplier, or patient doesn’t le a
proper claim with the GHP (or Large Group Health Plan (LGHP)) due to the patient’s physical or mental
incapacity. The provider, physician, or other supplier must prove the patient’s physical or mental incapacity
prevented them from providing other payer information, which led to the failure to le a proper claim.
If the patient has a primary GHP and the provider doesn’t bill the primary GHP rst, we won’t pay
conditionally on the liability (including self-insurance), no-fault, or WC claim. Providers must bill the
GHP before billing Medicare. We won’t pay for conditional primary benets for non-ORM claims in
other situations where the:
●
GHP says it’s secondary to Medicare
●
GHP limits its payment when the patient is entitled to Medicare
●
GHP covers the services for younger employees and spouses, but not for employees and spouses
65 and older
●
GHP says it’s secondary to liability, no-fault, or WC insurance
●
The provider doesn’t le a proper and timely claim with Medicare
Additionally, we won’t make conditional payments associated with WCMSAs or when ORM exists.
MLN BookletMedicare Secondary Payer
Page 14 of 20 MLN006903 October 2023
Paid Promptly
For non-ORM no-fault insurance and WC claims, paid promptly means payment within 120 days
after the no-fault insurance or WC got the claim for specic items and services. Without contradicting
information, treat the specic items and services date as the claim date when determining the paid
promptly period; for inpatient services, treat the discharge date as the service date.
For non-ORM liability insurance (including self-insurance), paid promptly means payment within
120 days of the:
●
Date someone les a general liability claim with an insurer or a lien against a potential liability settlement
●
Date service provided or, in the case of inpatient services, the discharge date
Find more information on conditional payments in:
●
Section 20.7 of the Medicare Secondary Payer Manual, Chapter 1
●
Sections 40 and 60 of the Medicare Secondary Payer Manual, Chapter 2
●
Sections 30 and 40.3.1 of the Medicare Secondary Payer Manual, Chapter 3
●
Section 40.6 of the Medicare Secondary Payer Manual, Chapter 5
●
Sections 40.3 and 60 of the Medicare Secondary Payer Manual, Chapter 6
Ongoing Responsibility for Medicals (ORM)
We can’t pay claims that are already paid or when payment can reasonably be expected from liability
insurance (including self-insurance), no-fault insurance, WC, or plan.
When a primary plan reports ORM to Medicare, it assumes payment responsibility, on an ongoing
basis, for certain accident- or injury-related medical care. We won’t pay for a patient’s injury care
without documentation the ORM terminated or exhausted.
If there’s not an ORM open record and the liability, no-fault insurance, or WC insurer won’t pay promptly,
you must bill the no-fault insurer rst to get the denial. You may bill Medicare for conditional payment
after rst getting a denial on a remittance advice. Medicare may pay depending on the reason for denial.
The Medicare Secondary Payer: Don’t Deny Services & Bill Correctly fact sheet has more information
to help you determine the payer order, how to bill MSP NGHP, how to bill a WCMSA claim, and how
to bill accident insurance for ORM and non-ORM claims.
Collecting Patient Health Insurance Information
COB allows plans to determine their payment responsibilities. The MSP contractor collects, manages, and
reports other patient insurance coverage to the CWF. Providers, physicians, and other suppliers must
collect accurate MSP information from the patient to ensure claims are led properly.
MLN BookletMedicare Secondary Payer
Page 15 of 20 MLN006903 October 2023
The MSP contractor relies on health insurance program stakeholders, including:
●
Federal and state programs
●
Plans that oer health insurance, prescription coverage, or both
●
Pharmacy networks
●
Variety of assistance programs
Some reporting methods we use to get MSP and COB information include:
●
Voluntary Data Sharing Agreement (VDSA): VDSA allows CMS and an employer to
electronically exchange GHP eligibility and Medicare information. The VDSA includes Medicare
Part D information, allowing VDSA partners to submit primary or secondary (retiree) records with
Part D prescription drug coverage.
●
MSP Mandatory Reporting Process: Section 111 of the Medicare, Medicaid, and SCHIP
Extension Act of 2007 (MMSEA) requires mandatory MSP data sharing requirements for GHP
insurance arrangements, liability insurance (including self-insurance), no-fault insurance, and WC
to report patient MSP information.
●
MSP Claims Investigation: The MSP contractor investigates when it learns another insurance
plan may have primary responsibility for paying a patient’s Medicare claims. The MSP contractor
determines if information is missing from MSP records or MSP cases. Single-source
investigations, which oer a centralized MSP-related inquiries location, involve collecting other
health insurance or coverage that may be primary to Medicare based on information submitted on
a medical claim or other sources like correspondence, accident and injury cases, or phone calls.
●
Electronic Correspondence Referral System (ECRS): ECRS is a web-based application that
allows MAC representatives and CMS Regional Oce MSP sta to electronically send possible
MSP lead information or questions about existing MSP records to the MSP contractor. ECRS
allows our authorized contractors and CMS Regional Oces to complete various online forms,
electronically transmit change requests to existing CWF MSP information, and inquire about
possible MSP coverage. The COB contractor automatically stores transactions in their system.
Each evening, a batch process reads the transactions and processes the requests.
●
Coordination of Benets Agreement (COBA) Program (non-MSP process; this involves
Medigap-type plans only): The COBA Program establishes a national standard contract between
the MSP contractor and other health insurance organizations to send enrollee eligibility data and
Original Medicare paid claims data. This means Medigap plans, employer supplemental plans,
Medicaid, and others rely on a national information repository with unique identiers to get and
cross over Medicare-paid claims data. The COBA data exchange processes include prescription
drug coverage former employers provide to people after they retire.
Note: Medicare is usually always primary for patient claims exchanged as part of COBA.
MLN BookletMedicare Secondary Payer
Page 16 of 20 MLN006903 October 2023
Provider & Supplier Responsibilities
●
Gather accurate MSP data by asking patients or their representatives questions about other
(potential) health insurance coverage that could be primary to Medicare. Do this at each visit
before providing services. Check eligibility to verify whether other primary insurance information
exists. It’s important for providers to maintain an admissions process that identies primary
payers, other than Medicare, to prevent incorrect billing and overpayments. Based on this
requirement, hospitals must document and maintain patient MSP information.
●
Identify all known primary payers to Medicare on the claim. Bill any primary payer before
billing Medicare.
●
Submit any MSP information on your claim using proper payment information, value codes,
condition, and occurrence codes, etc. If you’re submitting an electronic claim, include the
necessary MSP claims processing elds, loops, and segments.
●
It’s important to note that you can’t deny medical services or entry to a skilled nursing facility or
hospital if you discover an open or closed GHP or NGHP, no-fault, WC MSP record, or a claim
Medicare mistakenly denies due to an MSP occurrence in the patient’s Medicare eligibility le.
Doing so is against Medicare laws and policies.
If you’re an institutional provider, you should:
●
Ask patients to update their insurance proles at each visit. The updates include MSP information,
like GHP information or NGHP coverage resulting from an injury or illness, before providing services.
●
Incorporate patient responses to MSP questions and eligibility verication from the HETS 271
response transaction in your health records.
●
Review or administer the MSP questions each time you treat or admit the patient.
●
Identify all known primary payers to Medicare on the claim.
●
Submit claims to the appropriate primary payer rst.
●
Submit MSP information to the MAC using proper claim condition, occurrence, and value codes
(for providers using Form CMS-1450 or its electronic equivalent).
●
Submit an explanation of benets or remittance advice from any other insurers with all appropriate
MSP information to the MAC on the hard copy claim. Provide the necessary information in the
appropriate elds, loops, and segments required to process an 837I electronic MSP claim.
●
Provide updated information to government agencies as appropriate.
MLN BookletMedicare Secondary Payer
Page 17 of 20 MLN006903 October 2023
Part B Providers (Physicians, Practitioners, & Suppliers)
●
Gather accurate MSP data. Determine if we’re the primary payer by asking patients or their
representative for MSP information.
●
Bill the primary payer before billing us.
●
Submit an explanation of benets or remittance advice from the primary payer with all MSP information
on your hardcopy claim. If you’re submitting an electronic claim, include the necessary information
in the appropriate elds, loops, and segments required to process an 837P electronic claim.
●
Provide updated information to government agencies as appropriate.
Section 70 of the Medicare Claims Processing Manual, Chapter 1 has more information on Medicare-
covered services timely ling requirements.
Gathering Accurate Data
Providers must keep responses to completed MSP questions and other MSP information for 10 years
after the service date. You may keep hard copy les or store them electronically. Keep negative and
positive question responses.
Once you collect information about other patient payers, report it on the claim. Our billing claim forms
(CMS-1450 and CMS-1500, and their electronic equivalents) have several MSP information elds.
Complete the necessary elds to identify other payers and other payer payment information.
Calculating Payment
Once the primary payer pays a claim, we use that information (with any applicable patient
deductible and coinsurance) to calculate our secondary payment. Section 40.8.3 of the
Medicare Secondary Payer Manual, Chapter 5 details specic formulas and payment calculations.
The calculation uses claim information and the primary payer’s explanation of benets or remittance
advice data for hard-copy claims.
MSP Contractor Claims Investigation
If you don’t provide records of other health insurance or coverage that may be primary to Medicare
on a claim, the MSP contractor may request the patient or their representative complete a Secondary
Claim Development Questionnaire. The MSP contractor may send this questionnaire when the:
●
MAC gets a claim with explanation of benets or remittance advice from an insurer other than Medicare
●
MAC gets an electronic claim with other insurance payment information in loops and segments
●
Patient self-reports or patient’s attorney identies an MSP situation
●
Third-party payer submits MSP information to the MAC or MSP contractor
The Reporting Other Health Insurance webpage has more information on secondary claim development.
MLN BookletMedicare Secondary Payer
Page 18 of 20 MLN006903 October 2023
Submit Claims With Other Insurer Information
We may mistakenly pay a claim as primary if it meets all billing requirements, including coverage
and medical necessity guidelines. However, if the patient’s CWF MSP record shows another insurer
should pay primary to Medicare, we’ll deny the claim.
If a MAC doesn’t have complete information about other primary insurance on the claim, they’ll send
a request to the MSP contractor to get additional information. The MSP contractor may request the
patient, employer, insurer, or attorney complete a Secondary Claim Development Questionnaire
for the additional information. After the MSP contractor gets the completed form, they’ll review the
questionnaire responses and take necessary action.
The Medicare Secondary Payer Manual, Chapter 3 has more information on MSP billing.
File Proper & Timely Claims
File a proper and timely claim with the primary payer. Check with the payer for their specic policies.
Federal law allows Medicare to recover incorrect payments. We require you to return any payment
we incorrectly paid as the primary payer. Generally, for MSP GHP situations, we recover improper
payments. We can ne providers, physicians, and suppliers for knowingly, willfully, and repeatedly
giving inaccurate information about other health insurance coverage.
We may recover incorrect payments directly from a primary payer, other entity, or third payer.
Medicare’s right to recover payments takes priority over any other party, including Medicaid.
A primary payer, or entity paid by a non-Medicare primary payer, has 60 days to reimburse Medicare.
This 60-day period begins on the date we get information that payment was, or could be made, by a
primary payer.
If you don’t reimburse us before the period’s expiration, we may charge interest for the violation. We
may also bring legal action to recover our primary payments, which may include double damages
recovery (twice the payment amount).
MLN BookletMedicare Secondary Payer
Page 19 of 20 MLN006903 October 2023
MSP Contact Information
Table 3. Who to Contact with MSP Questions
Contact Question
Benets Coordination & Recovery
Center (BCRC) Customer Service
Representatives
Monday–Friday (except holidays)
8 am–8 pm, ET
Toll free lines:
1-855-798-2627
Text Telephone (TTY) or
Telecommunication Device for the
Deaf (TDD): 1-855-797-2627
● Ask about Medicare development letters and questionnaires
● Report a patient’s accident or injury on the claim you
submit to your MAC
● Report a patient’s employment or health insurance
coverage changes on your claim to Medicare
● Verify Medicare’s primary or secondary status
The Provider Services webpage has guidance on reporting a
patient’s health insurance changes.
Request patient MSP information before billing. To protect
patients’ rights and information, the BCRC MSP contractor
can’t disclose this information.
MAC
●
Ask general questions, including how to bill
●
Ask about processing specic claims
●
Ask about Medicare claim or service denials,
adjustments, and claim appeals
●
Ask about voluntary refunds
●
Ask about returning inappropriate Medicare payments
●
The Commercial Repayment Center (CRC) MSP contractor is responsible for GHP recoveries and
activities related to recovering improper payments
●
The BCRC MSP contractor is responsible for liability, no-fault, and WC recoveries
●
The BCRC and CRC MSP contractor manages all COB and recovery activities except for the
Medicare Prescription Drug, Improvement, and Modernization Act of 2003 demonstration recovery
demand letters that MSP recovery auditors issue
The GHP Recovery and NGHP Recovery webpages have more information regarding MSP recoveries.
MLN BookletMedicare Secondary Payer
Page 20 of 20 MLN006903 October 2023
Resources
●
Billing for Services when Medicare is a Secondary Payer
●
Medicare & Other Health Benets: Your Guide to Who Pays First
●
Medicare Secondary Payer
●
Medicare Secondary Payer Manual
View the Medicare Learning Network® Content Disclaimer and Department of Health & Human Services Disclosure.
The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department
of Health & Human Services (HHS).
