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This course is designed to provide Medicare Part A providers
with an understanding of:
• The various types of Medicare Secondary Payer (MSP)
provisions;• How to determine when Medicare is primary or
secondary; and• A general overview of requirements for submitting
MSP claims.
Course updated: November 30, 2015 Copyright 2013 Cahaba
Government Benefit Administrators, ® LLC
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The Medicare Secondary Payer (MSP) Provisions of section 1862(b)
of the Social Security Act protect Medicare funds by ensuring that
federal funds are not used to pay for services that are
reimbursable under any private insurance plan. These entities
include group health plans, workers’ compensation plans, liability
insurance, or no-fault insurance. The MSP provisions apply to
situations where Medicare is not the beneficiary’s primary
insurance.
Medicare Secondary Payer
Medicare Secondary Payer: Exceptions to the MSP Requirement
In most cases, Federal law takes precedence over state laws and
private contracts. Even if a state law or insurance policy states
that they are a secondary payer to Medicare, the MSP provisions
should be followed when billing for services.
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• Working Aged - Beneficiary is 65 or older• Disability -
Beneficiary is under 65• Veterans Administration• Federal Black
Lung• End Stage Renal Disease• No-Fault Insurance• Liability
Insurance• Workers' Compensation
MSP Provisions
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• Has group health plan (GHP) coverage through own/spouse's
employer with 20 or more employees
• When the working beneficiary or spouse retires, Medicare
becomes primary.• When billing this provision, use value code 43
and appropriate payer code(s)
and/or occurrence code(s).
MSP Provisions: Working Aged
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• Under age 65 and on Medicare due to disability.• Has group
health plan (GHP) coverage through own/ family member’s
employer• Employer has 100 or more employees to qualify as a
Large Group Health Plan
(LGHP).• When billing this provision, use value code 43 and
appropriate payer code(s)
and/or occurrence code(s).
MSP Provisions: Disability
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• Beneficiaries who have VA can choose to have their claims
filed to VA or Medicare.
• Medicare will pay in the following situations:• VA benefits
were not claimed;• VA did not cover the service.• When billing this
provision, use value code 42 and appropriate payer code(s)
and/or occurrence code(s).
MSP Provisions: Veteran’s Administration (VA)
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• Program provides benefits to coal miners for lung conditions
attributable to coal mining.
• Medicare will reject a claim if BL diagnosis appears anywhere
on the claim. Submit to Department of Labor (DOL) first to
determine what they will cover.
• Medicare will pay if service is not covered by DOL.• When
billing this provision, use value code 41 and appropriate payer
code(s)
and/or occurrence code(s).
MSP Provisions: Federal Black Lung (BL)
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• Has group health plan (GHP) coverage through own/ family
member’s current or former employer during 30-month coordination
period.
• 30-month coordination period is the period of time when the
GHP will pay first and Medicare will pay second and begins the
first month a patient is eligible for Medicare due to kidney
failure (usually the fourth month of dialysis).
• Provision applies to all Medicare covered items and services
(not just treatment of ESRD) furnished during coordination
period.
• When billing this provision, use value code 13 and appropriate
payer code(s) and/or occurrence code(s).
MSP Provisions: End Stage Renal Disease (ESRD)
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Under §1862(b)(2) of the Act, (42 U.S.C. 1395y(b)(1)), Medicare
does not make payment for covered items or services to the extent
that payment has been made, or can reasonably be expected to be
made under no-fault insurance or a liability insurance policy or
plan (including a self-insured plan).
• When billing for the No-Fault provision, use value code 14 and
appropriate payer code(s) and/or occurrence code(s).
• When billing for the Liability provision, use value code 47
and appropriate payer code(s) and/or occurrence code(s).
MSP Provisions: No-Fault or Liability
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• Medicare will pay for services in the following situations: WC
benefits are exhausted; Conditionally if the WC case is in
litigation; If the service is not related to the WC injury,
provided no other group coverage
exists that falls under the MSP provisions.• When billing this
provision, use value code 15 and appropriate payer code(s)
and/or occurrence code(s).• If payment for services cannot be
made by WC because they were furnished
by a source not authorized by WC, such services can be paid for
by Medicare.• Medicare remains primary for all medical services not
related to the work
related injury, provided no other group coverage exists that
falls under the MSP provisions.
MSP Provisions: Workers’ Compensation (WC)
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• Medicare may make secondary payment on claims that are denied
by the Primary Payer if the services are covered by Medicare and a
proper claim has been filed to the Primary Payer and to
Medicare.
• In these situations, providers must provide information from
the Primary Payer stating the claim has been denied. For paper
submitters, this would be an Explanation of Benefits (EOB) from the
Primary
Payer stating that the claim has been denied. For electronic
submitters, the following information is required: Medicare
indicated as
the secondary payer, insurance type, Coordination of Benefits
(COB) payer paid amount, COB allowed amount, claim adjudication
date, service line data, line adjudication data, line adjudication
information, and any line adjustments(s) with the accompanying line
adjudication date(s).
MSP Payments: When Will Medicare Make A Secondary Payment?
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A contractual obligation (CO) arises as a result of an
enforceable promise, agreement, or contract. If a provider is
obligated to accept, or voluntarily accepts, an amount as payment
in full from the primary payer, this is a contractual
obligation.
For contractual obligations, use value code 44 and amount.
• The Obligated To Accept as Payment in Full Amount (OTAF) is
the amount the provider agreed to accept as payment in full for a
service rendered under the provisions of the primary payer's
contract. When a primary payer allows less than the billed amount
and the provider is contractually obligated to accept that amount
as payment in full, then the allowed amount is the OTAF amount.
• The difference between billed amount and contractual
obligation amount that the primary insurance allowed cannot be
billed to the beneficiary.
MSP Payments: Contractual Obligations
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Conditional payment is a Medicare payment, conditioned upon
reimbursement to Medicare, for services which another insurer is
the primary payer and has not paid and cannot reasonably be
expected to make payment promptly.
With regard to no-fault and WC insurance, promptly means payment
within 120 days after receipt of the claim. For liability
insurance, promptly means payment within 120 days after the earlier
of the following:
• The date a claim is filed with an insurer or a lien is filed
against a potential liability settlement; or
• The date the service was furnished or, in the case of
inpatient hospital services, the date of discharge.
Use the Remarks Field to explain reasons for nonpayment and to
justify conditional payments. For Working Aged and Disability,
enter employer’s name and address that provides the primary
insurance.
MSP Payments: When Will Medicare Make A Conditional Payment?
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MSP situations are determined by:
1. MSP questionnaire conducted by provider at time of
admission2. Benefits Coordination and Recovery Center (BCRC)3.
Accessing patient information through ELGA
MSP Situations: Three Ways to Determine if MSP Situations
Exist
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MSP Situations: MSP QuestionnaireProviders, physicians and other
suppliers may use a model questionnaire published by the Centers
for Medicare and Medicaid Services to collect patient information.
This tool is available online in the MSP Manual in chapter 3,
section 20.2.1
at:https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/msp105c03.pdf
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/msp105c03.pdf
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The Benefits Coordination and Recovery Contractor (BCRC) was
created to centralize and consolidate activities that support the
collection, management and reporting of other insurance coverage
for Medicare beneficiaries.
The main purpose/role of the BCRC program is to:• Administer the
MSP program more effectively and efficiently by utilizing a
single
contractor entity to operate, coordinate and maintain the MSP
processes and generate cost savings through a reduction in mistaken
primary Medicare payments.
• Identify which health benefits are available to a Medicare
beneficiary.• Assist in the continuous campaign against Medicare
fraud, waste and abuse under the
Medicare Integrity Program (MIP).
MSP Situations: BCRC
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Contact the BCRC to:• Report other insurance coverage
information.• Report or provide updated information on a liability,
auto/no-fault,
or workers compensation case.• Ask general Medicare Secondary
Payer (MSP) questions/concerns.• Ask questions regarding Medicare
Secondary Development letters and
questionnaire.
BCRC Customer Call Center• 1-855-798-2627 TDD/TYY
1-855-797-2627• Monday through Friday 8:00 a.m. to 8:00 p.m.
Eastern Time (except holidays)
Specific claim-based issues (including claim processing) should
still be addressed to the Provider Contact Center at the Medicare
Administrative Contractor.
MSP Situations: Contacting the BCRC
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Access ELGA - Page 9 and beyond (if MSP situation exists).
• ELGA will have one additional page for each MSP record. Page 9
would be MSP record 1, page 10 would be MSP record 2, etc.
• ELGA provides detailed information including the insurer’s
name and address, and the policy number for the insured.
• Page 9 only appears if an MSP record exists.
MSP Situations: ELGA
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MSP Situations: ELGA Screen Information
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Effective 10/05/2009, initial and/or adjustment MSP claims are
no longer accepted into the Fiscal Intermediary Shared System
(FISS) via Direct Data Entry (DDE). MSP Claims can be submitted
via:
• An Electronic Media Claim (EMC) using a HIPAA compliant
version of ANSI ASC X12N 837 format;
• PC-ACE Pro32;• Hardcopy UB-04/CMS-1450 (if qualified for a
paper exception).
For more information, review Change Request 6426:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R70MSP.pdf
For more information on the Administrative Simplification
Compliance Act (ASCA) Enforcement of Mandatory Electronic
Submission of Medicare Claims, review Change Request 3440:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R450CP.pdf
MSP Claim Submission
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R70MSP.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R450CP.pdf
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Medicare Secondary Payer Manual (CMS Pub.
100-05),https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.html?redirect=/Manuals/IOM/list.asp–
Chapter 1 – Background and Overview– Chapter 2 – MSP Provisions–
Chapter 3 – MSP Provider Billing Requirements
MSP Fact
Sheethttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MSP_Fact_Sheet.pdf
Cahaba Educational
Material:https://www.cahabagba.com/cahaba-u/part_a/msp/html/index.htm
Resources: CMS and Other Resources
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.html?redirect=/Manuals/IOM/list.asphttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MSP_Fact_Sheet.pdfhttps://www.cahabagba.com/cahaba-u/part_a/msp/html/index.htm
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Click the link below and complete the Medicare Secondary Payer
Post-test:
http://w3.mccg.org/iota/test-medicare-secondary-payer-a.asp
When the test is successfully completed, you will be prompted to
enter information to record your
results.
http://w3.mccg.org/iota/test-medicare-secondary-payer-a.asp
Slide Number 1Medicare Secondary PayerMSP ProvisionsMSP
Provisions: Working AgedMSP Provisions: DisabilityMSP Provisions:
Veteran’s Administration (VA)MSP Provisions: Federal Black Lung
(BL)MSP Provisions: End Stage Renal Disease (ESRD)MSP Provisions:
No-Fault or LiabilityMSP Provisions: Workers’ Compensation (WC)MSP
Payments: �When Will Medicare Make A Secondary Payment?MSP
Payments: Contractual ObligationsMSP Payments: �When Will Medicare
Make A Conditional Payment?MSP Situations: �Three Ways to Determine
if MSP Situations ExistMSP Situations: MSP QuestionnaireMSP
Situations: BCRCMSP Situations: Contacting the BCRCMSP Situations:
ELGAMSP Situations: ELGA Screen InformationMSP Claim
SubmissionResources: CMS and Other ResourcesClick the link below
and complete the Medicare Secondary Payer Post-test: