Part B Other Insurer Intake Tool
For Medicare programs to work effectively, providers have a significant responsibility for the collection and maintenance of patient information. They must ask questions to secure employment and insurance information. They have a responsibility to identify payers other than Medicare so that incorrect billing and overpayments are minimized. Providers must determine if Medicare is the primary or secondary payer. The beneficiary must be queried about other possible coverage that may be primary to Medicare. Failure to maintain a system of identifying other payers is viewed as a violation of the provider agreement with Medicare.
There are many insurance benefits a patient could have and many combinations of insurance coverage to consider before determining who pays first. Depending on the type of additional insurance coverage, if any, a patient has, Medicare may be the primary payer for a beneficiary’s claim(s) or considered the secondary payer.
There are programs under which payment for services is usually excluded from both primary and secondary Medicare benefits.
- Veteran’s Administration (VA) Benefits - Medicare does not pay for the same services covered by VA benefits. For further information about VA benefits contact the VA Administration at 1-800-827-1000.
- Federal Black Lung Benefits - Medicare does not pay for services covered under the Federal Black Lung Program. However, if a Medicare-eligible patient has an illness or injury not related to black lung, they may submit a claim to Medicare. For further information contact the Federal Black Lung Program at 1-800-638-7072.
Medicare is the Secondary Payer when beneficiaries are:
- Treated for a work-related injury or illness. Medicare may pay conditionally for services received for a work-related illness or injury in cases where payment from the state workers’ compensation insurance is not expected within 120 days. This conditional payment is subject to recovery by Medicare after a workers’ compensation settlement has been reached. If WC denies a claim, or a portion of a claim, a claim can be filed with Medicare for consideration of payment.
- Treated for an illness or injury caused by an accident and liability and/or no-fault insurance will cover the medical expenses as the primary payer.
- Covered under their own employer’s or a spouse’s employer’s group health plan (GHP).
- Disabled with coverage under a large group health plan (LGHP).
- Afflicted with permanent kidney failure (End-Stage Renal Disease (ESRD)) and are within the 30-month coordination period.
Use the “MSP Questionnaire” to determine the primary payer of the beneficiary’s claims. The tool consists of six parts and lists questions to ask Medicare beneficiaries. Use this tool as a guide to help identify other payers that may be primary to Medicare. Beginning with Part 1, ask the patient each question in sequence. Comply with all instructions that follow an answer. If the instructions direct you to go to another part, have the patient answer, in sequence, each question under the new part. Note: There may be situations where more than one insurer is primary to Medicare (e.g., Black Lung Program and GHP). Be sure to identify all possible insurers.